Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marine Creek Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident under 22 years old with severe TBI, ventilator dependence, total ADL dependence, and multiple complex medical needs did not receive required permanency planning services. State-contracted permanency planning staff repeatedly emailed and called the facility’s SW requesting records and providing official guidance and Form 2437, but the SW, unfamiliar with permanency planning, questioned the legitimacy of the request, did not document or escalate it, and did not respond. The CD believed permanency planning applied only to PASRR-positive residents and took no action after a negative PASRR evaluation, and the facility had no policy on permanency planning. As a result, the facility failed to provide medically related social services necessary to support permanency planning for this under-22 resident.
Two assisted lifting devices were found improperly secured in facility hallways, with one left free rolling and another locked by only one wheel, despite staff training on proper procedures. Residents were observed walking past these unsecured devices, and both staff and the DON acknowledged the risk of accidents from improper storage.
Two residents with behavioral and psychiatric histories engaged in escalating verbal and physical altercations, culminating in one resident being punched in the face by the other. Staff were aware of prior conflicts and complaints but did not separate the residents or implement effective interventions, resulting in physical injury and a failure to protect residents from abuse as required by facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Feeding tubes were utilized for a resident without documented medical justification or resident consent, and appropriate care for a resident with a feeding tube was not provided.
The facility failed to ensure that emergency crash carts were properly stocked and checked daily, resulting in a missing Ambu bag on one cart and incomplete inventory checks on another. Staff interviews revealed confusion over responsibility for maintaining the carts, and the DON was not aware of the facility's policy regarding daily checks. These deficiencies could delay emergency care for residents in need of basic life support.
A resident with multiple complex medical conditions, including COPD and on hospice care, was placed on a non-rebreather mask for high-flow oxygen without a physician order and with incorrect oxygen flow rates for several days. Staff were unclear about the need for specific orders and proper mask settings, and the resident's care plan was not updated to reflect this change in respiratory therapy.
A nurse without proper training in non-rebreather mask use administered oxygen therapy at an incorrect flow rate to a resident with COPD and other complex conditions. The resident's care plan did not include non-rebreather use, and there was a lack of appropriate physician orders and documentation. Interviews confirmed that staff were unfamiliar with correct procedures, and the facility's policy on oxygen administration was not followed.
A facility failed to label a resident's enteral nutrition formula and water bags with the date and time, as required. This oversight was observed during a survey, where the resident, who had a history of acute respiratory failure and required enteral feeding, was at risk of malnutrition and dehydration. Staff interviews confirmed the labeling should have been done, but the facility's policy did not specify this requirement.
A resident's right to retain personal possessions was violated when the Administrator took away her cell phone after she repeatedly called 911 due to breathing difficulties. The resident, who was ventilator-dependent, was unable to speak to the 911 operator. The phone was returned within 10 minutes after the family was informed and communicated with the resident to stop the calls.
A resident with dementia and schizophrenia was verbally abused by a CNA who attempted to force her to bed, witnessed by family via a video camera. The resident's care plan, which included interventions for behavior management, was not followed, leading to the escalation of the situation. The incident was not reported by the assisting LVN, contrary to the facility's abuse policy.
A facility failed to maintain a safe environment for a legally blind resident requiring supervision with bed mobility. The resident's bed was lopsided, causing discomfort and potential fall risk. Despite the resident's report to the Maintenance Director, the issue persisted. The DON and Administrator did not perceive a risk, and no accident prevention policy was provided.
The facility failed to maintain an effective pest control program, leading to the presence of flies and roaches. Residents reported sightings of roaches in their rooms, and flies were observed on a mattress. The Maintenance Director confirmed weekly pest control visits, but issues persisted. Pest control records showed multiple roach sightings, and the DON and Administrator were unaware of the problem's extent.
The facility failed to provide proper respiratory care for two residents, as their nasal cannulas were not bagged for sanitation and their oxygen concentrators were contaminated with debris. Despite being cognitively intact, the residents' care plans were not followed, leading to potential risks of respiratory infections. Interviews revealed inconsistencies in staff responsibilities for maintaining oxygen equipment, and the facility's policy did not address proper storage of tubing.
A resident with severe cognitive impairment was left exposed and naked when an LVN and a contractor entered the room without closing the privacy curtain. The LVN, unfamiliar with the resident's care needs, focused on locating an oxygen concentrator, leading to a breach of privacy. The facility's policy emphasized dignity and privacy, but the incident highlighted a failure to uphold these standards.
A resident with Muscular Dystrophy and quadriplegia did not receive scheduled showers, as required for her care, due to staff not offering them consistently. Despite being cognitively intact and dependent on staff for bathing, the resident reported long periods without showers, which was confirmed by facility records. Staff interviews revealed a lack of documentation for shower refusals, and the facility's policy on bathing was not followed, impacting the resident's hygiene and well-being.
A facility failed to document physician orders for ventilator settings for a resident with complex medical needs, including chronic respiratory failure and ALS. Despite the resident's dependence on a mechanical ventilator, the necessary orders were not recorded from the time of readmission. Staff interviews revealed that the ventilator settings were known and monitored, but the admitting nurse did not document the orders. The facility could not provide a policy for physician orders, indicating a gap in adherence to existing policies.
A long-term care facility failed to maintain an effective infection control program, as observed by surveyors. An LVN did not disinfect a blood sugar monitoring device between uses on multiple residents and failed to perform hand hygiene. Additionally, an RN did not adhere to enhanced barrier precautions when administering G-tube medication, neglecting to wear PPE and perform hand hygiene. Staff interviews revealed a lack of awareness and training on infection control procedures.
A fly infestation in the dining room affected three residents, including a cognitively intact male with a history of stroke, a male with severe cognitive impairment, and a female with moderate cognitive impairment. Despite regular pest control treatments, flies were observed on residents and tables, impacting their dining experience.
The facility failed to ensure call lights were within reach for two residents, both with moderate cognitive impairments and fall risks. One resident's call light was found under the fitted sheet, while another's was on the floor. Staff interviews revealed a lack of adherence to care plans requiring call light accessibility, and the facility lacked a policy to ensure compliance.
A facility failed to ensure privacy and confidentiality for residents in a shared room by not obtaining proper consents for an AEM camera. A resident with severe cognitive impairment had a camera placed in their room without consent from the roommate, leading to potential exposure of personal information. Staff interviews revealed a lack of clear policy and responsibility for managing AEM consents.
A resident with complex medical needs did not receive proper G-tube care, as the facility failed to change the water bag and enteral administration set with formula changes. This oversight, observed during a survey, was due to inadequate adherence to procedures and insufficient staff training, increasing the risk of infection.
A resident with complex medical conditions was admitted with a PICC line, but the facility failed to obtain necessary orders or perform required dressing changes, placing the resident at risk for infection. Staff interviews revealed a lack of clarity and action regarding PICC line management, and the facility did not provide a policy for PICC/IV dressing changes, contrary to CDC guidelines.
The facility failed to secure medication and respiratory treatment carts, leaving them unlocked and unattended in hallways. Staff interviews confirmed that the carts should be locked when not in use, as per facility policy, to prevent unauthorized access to medications.
A facility failed to notify the State LTC Ombudsman of a resident's transfer to the hospital, as required by policy. The resident, with chronic respiratory issues, was transferred after reporting shortness of breath and chest pain. Interviews revealed confusion among staff about who was responsible for sending discharge notices, leading to the oversight. The facility's policies mandate notification to the resident, their representative, and the ombudsman, which was not followed in this case.
A resident with chronic respiratory issues and a tracheostomy was transferred to a hospital without receiving written information about the facility's bed-hold policy. Upon readiness to return, the facility had no available bed, as confirmed by staff interviews. The facility's admission packet required bed-hold information to be provided, but this was not done.
A resident with a tracheostomy experienced severe health issues due to the facility's failure to adhere to recommended tracheostomy tube cuff pressure. The resident's cuff was chronically overinflated, leading to vertebral remodeling and swallowing difficulties, which likely caused starvation ketoacidosis. Despite staff awareness of the resident's requests for more air, proper procedures were not followed, and the issue went unaddressed until the resident was hospitalized.
A facility failed to provide adequate respiratory care for residents requiring oxygen therapy and CPAP use. Observations revealed undated and unbagged oxygen tubing and CPAP masks, with staff interviews indicating lapses in equipment management practices. These deficiencies affected residents with conditions such as COPD and acute respiratory failure, highlighting inconsistencies in following facility policies for infection prevention.
A resident with severe cognitive impairment and multiple medical conditions exhibited behaviors such as not using the call light and removing his CPAP mask, which were not reflected in his care plan. Despite staff awareness of these behaviors, the care plan was not updated, potentially risking inadequate care. The facility's policy requires person-centered care plans, but a communication gap led to this oversight.
A resident's call light was found on the floor and not within reach, despite the care plan requiring it to be accessible. The resident, who was severely cognitively impaired and required maximal assistance, was agitated and stated that no one had come to help him. Staff were unaware of the call light's location, and the facility lacked a call light policy.
A resident with a history of dementia, diabetes, falls, and muscle weakness was found on the floor by a student nurse aide during the evening shift. The incident was not reported to the charge nurse until several hours later, resulting in a delay in medical assessment and care. The resident sustained significant bruising and injury to the right side of the face and head. The delay highlighted gaps in staff training and awareness, as well as confusion and miscommunication regarding incident reporting and response procedures.
A facility did not adhere to its written policies and procedures designed to prevent abuse, neglect, and exploitation of residents. An incident involving a resident with dementia, diabetes, falls, and muscle weakness highlighted this deficiency. A Student Nurse Aide found the resident on the floor with significant bruising and head injury but failed to report the incident to the charge nurse. This resulted in a delay in the resident receiving necessary treatment, including neurological checks and physician notification. The facility's policies emphasize timely reporting in such cases, but staff training and awareness of protocols were insufficient.
A resident with severe cognitive impairment and a history of wandering behaviors exited into an enclosed courtyard during a storm and remained outside for approximately 3 hours. The door to the courtyard, which required a code to open, was left unlocked or unsupervised when its locking mechanism lost power. The resident's care plan included interventions to prevent elopement, but these measures were not effectively implemented. The resident was found lying on the ground in the courtyard, prompting an investigation into the incident.
A facility failed to report a resident's fall and subsequent injuries in a timely manner. A student nurse aide found the resident on the floor but did not notify the charge nurse, resulting in a delay in treatment. The administrator also failed to report the incident to state authorities.
Failure to Provide Required Permanency Planning Services for a Resident Under 22
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically permanency planning services, to a resident under the age of 22 as required by Texas regulations. The resident was a young adult with a history of diffuse traumatic brain injury with loss of consciousness, ventilator dependence via tracheostomy, severe mobility limitations, GERD, generalized anxiety disorder, and depression. Her MDS reflected severe cognitive impairment, no speech, dependence on staff for all ADLs with two-person assist, risk for dehydration and shortness of breath, need for parenteral/IV feeding and feeding tube, risk for pressure ulcers, and multiple special treatments including oxygen, suctioning, tracheostomy care, invasive mechanical ventilation, and IV access. The care plan and MD orders documented extensive medical and nursing needs, including anticoagulant therapy, seizure disorder, bowel incontinence, enhanced barrier precautions, feeding tube management, and tracheostomy care. Despite the resident’s age and the Texas requirement that permanency planning be completed every six months for individuals under 22 residing in nursing facilities, the facility did not ensure that permanency planning was initiated or supported. The Permanency Planning Contractor (PPC) sent emails to the facility social worker (SW) on multiple dates with a provider letter explaining permanency planning requirements, a blank Form 2437 (Notification of Nursing Facility Admission of Person Under Age 22), and information that permanency planning is mandated under Texas Administrative Code. The PPC reported requesting records on several occasions and informing the SW that records were required within three days. The PPC also stated that a negative PASRR result would not prevent permanency planning services. However, the facility’s Clinical Director (CD) stated that permanency plans were only completed for PASRR-positive residents under age 22 and that, because the resident’s PASRR evaluation was negative, no further action was taken. The SW reported being unfamiliar with the term “permanency planning” and stated that when contacted by the PPC for the resident’s care files and related documents, she questioned the legitimacy of the request, was concerned about HIPAA and confidentiality, and did not feel comfortable providing information. She indicated that the PPC could not provide sufficient information about the resident’s relation and purpose of the request, and she did not document the contact, did not forward the emails to the DON or administrator, and did not contact HHSC, the PPC, or a PPC superior to verify the request. The SW initially denied receiving emails from the PPC, and it was only after the surveyor requested supporting documentation that the SW produced the email correspondence. Interviews also revealed that the DON and CD could not provide a facility policy on permanency planning, and both reported that no such policy existed. As a result of these actions and inactions—misunderstanding of PASRR’s role, failure to recognize and act on permanency planning requirements for a resident under 22, failure to respond to PPC requests, and lack of policy guidance—the facility did not provide the required medically related social services related to permanency planning for this resident. The resident remained non-interviewable during survey observations due to her traumatic brain injury, but she was observed awake in bed, ventilator-dependent, with clean equipment and environment, and able to visually track the surveyor. The record review confirmed that the resident had been in the facility for several months, and the SW’s own note documented initial contact from an individual stating the resident had been flagged by the state for permanency placement assistance due to age. The SW’s note also reflected her discomfort with the call, her belief that the caller’s identification as a state representative was questionable, and her decision not to proceed without consulting the family or administration, yet she did not follow through with leadership or regulatory contacts. The combination of the facility’s lack of a permanency planning policy, the SW’s lack of knowledge and failure to act on multiple PPC contacts, and the CD’s reliance on PASRR status instead of permanency planning regulations led directly to the failure to assist this under-22 resident in obtaining permanency planning resources and services as required. Additionally, the DON reported that she had completed the initial PASRR at admission, determined the resident was positive, and submitted the 2401 form to HHSC, after which a QIDP evaluation concluded the resident did not qualify for PASRR services. The DON stated that the family was informed of these PASRR results and agreed to services for the resident, and that the SW was assigned to contact the provider about the records request. However, the SW did not complete this assignment and did not engage with the PPC to move forward with permanency planning. The surveyor’s review of the SW’s personnel file showed that she had been hired earlier in the year at a sister facility and transferred to the current facility shortly before the PPC contacts, and there was no evidence that she had prior training on permanency planning before the in-service that occurred after the PPC’s initial outreach. The absence of a facility policy, combined with the SW’s inaction and the CD’s misunderstanding of regulatory triggers, resulted in the resident not receiving the medically related social services necessary to support permanency planning.
Failure to Secure Assisted Lifting Devices Creates Accident Hazards
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards in two of four hallways reviewed. Specifically, two of four assisted lifting devices were not properly secured while being stored in the hallways. Observations showed that one hydraulic assisted lifting device in the 200 hallway was left free rolling with unsecured wheels, and another device in the 400 hallway had only one wheel locked, allowing it to spin freely. Several residents were observed ambulating past these unsecured devices. Record review indicated that the facility's policy and user manual lacked clear instructions on proper storage and locking of these devices when not in use. Interviews with staff and the DON confirmed that training had been provided on locking all wheels of assisted lifting devices when not in use, and staff acknowledged the risk of accidents if devices were not properly secured. Despite this training, the devices were found unsecured or improperly secured during the survey, indicating a failure to consistently implement safety procedures for storing assisted lifting devices in resident areas.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in one resident being physically assaulted by another. The incident involved a resident with a history of hemiplegia, hemiparesis, cognitive communication deficit, and mood disorder, who was punched in the face by his roommate, a resident with diagnoses including bipolar disorder with psychotic features and intermittent explosive disorder. Prior to the altercation, there were documented verbal disagreements and escalating tensions between the two residents, including complaints about noise and mutual accusations of disruptive behavior. Staff were aware of at least one verbal disagreement the day before the physical altercation, but the residents were not separated or further interventions implemented to prevent escalation. On the night of the incident, the two residents engaged in a heated exchange that escalated to physical violence. One resident reported being struck in the mouth and chest, and sustaining a skin tear and scratches. Both residents provided accounts of the altercation, with each blaming the other for initiating the physical aggression. Staff interviews confirmed that the altercation was preceded by loud arguments and that a nurse intervened by removing one resident from the room, but the other resident followed and delivered a punch in the hallway. The facility's Director of Nursing and Assistant Director of Nursing acknowledged that there was prior knowledge of the residents' incompatibility and that the incident could have been prevented if staff had been informed of the escalating conflict. The facility's abuse and neglect policy requires prompt recognition, reporting, and investigation of abuse, including resident-to-resident altercations. However, the report indicates that staff did not act on early warning signs or previous behavioral history, such as the new resident's involvement in a prior altercation at another facility and the ongoing complaints from the other resident about his roommate. The lack of timely intervention and failure to separate the residents after initial signs of conflict directly contributed to the physical abuse incident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the procedure. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Maintain Emergency Crash Cart Supplies and Daily Checks
Penalty
Summary
The facility failed to ensure that basic life support equipment and procedures were consistently available and followed prior to the arrival of emergency medical personnel, as required by physician orders and residents’ advance directives. Specifically, Emergency Cart 1 was found to be missing an Ambu bag, a critical device for providing ventilation to residents who are struggling to breathe or have stopped breathing. Staff interviews revealed that the absence of the Ambu bag was justified by the presence of Ambu bags in residents’ rooms and in the central supply closet, but this did not align with facility policy, which required an Ambu bag to be present on the emergency cart itself. Additionally, the facility did not maintain proper daily inventory checks on Emergency Cart 2. Review of the emergency cart’s daily check-off logs showed multiple days where no inventory check was completed. Staff interviews indicated confusion and lack of clarity regarding responsibility for checking the emergency carts, with some nurses believing it was a shared responsibility and others stating it was assigned to specific staff. The facility’s policy required daily checks and immediate restocking after use, but this was not consistently followed. Further interviews with nursing and administrative staff revealed inconsistent understanding of the procedures for maintaining emergency carts. While some staff stated that night shift nurses were responsible for daily checks, others believed central supply was responsible for monthly checks and restocking. The Director of Nursing was not aware of the specific policy regarding daily checks and could not articulate the associated risks. The lack of clear assignment and adherence to policy resulted in emergency carts not being reliably stocked and ready for use, potentially delaying emergency care.
Failure to Obtain and Follow Physician Orders for Non-Rebreather Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, specifically the use of a non-rebreather mask for high-flow oxygen therapy, received care consistent with professional standards, physician orders, and the resident's care plan. The resident, an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD, was on hospice care and dependent on staff for all activities of daily living. Her care plan and physician orders specified oxygen therapy via nasal cannula at 2-4 liters per minute, but did not include orders for non-rebreather mask use or high-flow oxygen therapy. On several occasions, nursing staff and hospice personnel initiated the use of a non-rebreather mask for the resident when she experienced shortness of breath and low oxygen saturation. However, there was no documented physician order for this intervention, and the mask was set at oxygen flow rates below the recommended minimum for non-rebreather use (less than 10 liters per minute) for an extended period. Staff interviews revealed confusion and lack of familiarity with the appropriate use and settings for non-rebreather masks, as well as uncertainty about the process for obtaining and documenting physician orders for changes in oxygen delivery methods. The non-rebreather mask remained in use for several days without proper orders or adjustment to the correct oxygen flow rate, and the care plan was not updated to reflect this change in therapy. Documentation and interviews further indicated that communication between facility staff, hospice nurses, and respiratory therapists was inconsistent. Some staff assumed that existing oxygen orders covered the use of a non-rebreather mask, while others believed that emergency use did not require a new order. The Director of Nursing and other staff acknowledged that physician orders are required for all oxygen delivery methods, but this was not consistently followed. The lack of specific orders and failure to follow professional standards for respiratory care placed the resident at risk for inappropriate oxygen therapy.
Failure to Ensure Nurse Competency in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skill sets to care for residents as identified through assessments and care plans. Specifically, a nurse (RN A) was not trained in the use of a non-rebreather mask for oxygen therapy and was unfamiliar with the required oxygen flow parameters and when to discontinue its use. This resulted in a resident with multiple complex medical conditions, including COPD, being placed on a non-rebreather mask at an incorrect oxygen flow rate without appropriate physician orders or documentation in the care plan. The resident in question was an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD. She was dependent on staff for all activities of daily living and required oxygen therapy as part of her care. The care plan specified oxygen via nasal cannula at 2-4 L/min but did not include the use of a non-rebreather mask. Despite this, RN A placed the resident on a non-rebreather mask at 5 L/min following a hospice nurse's suggestion, although the standard for non-rebreather masks is a minimum of 10 L/min. RN A admitted to never having used a non-rebreather before and was not familiar with its proper use. Interviews revealed that the hospice nurse did not provide explicit orders to continue the non-rebreather mask and was unaware it was left on the resident for an extended period. Additionally, a hospice CNA reported finding the resident without oxygen or with an empty oxygen tank on several occasions and had to notify facility staff. The Director of Nursing confirmed that non-rebreather masks should be set at 10-15 L/min and would not expect them to be used at lower rates. The facility's policy required staff to be familiar with oxygen administration methods, but this was not followed in the resident's care.
Failure to Label Enteral Nutrition Bags
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with the appropriate treatment and services to prevent complications associated with tube feeding. Specifically, the facility did not label the formula and water bag with the date and time they were started, which is a critical step in managing enteral nutrition. This oversight was observed during a survey, where it was noted that the resident's formula and water bag lacked the necessary labeling, potentially placing the resident at risk of malnutrition and dehydration. The resident in question was a male with a history of acute respiratory failure with hypoxia, tracheostomy status, and gastrostomy status, requiring enteral feeding. The facility's policy on enteral nutrition did not specify the requirement for dating and timing the formula and water bags, which contributed to the deficiency. Interviews with staff, including an LVN and the Administrator, confirmed that the labeling should have been done, and the absence of such labeling could lead to the resident receiving incorrect nutrition levels.
Resident's Right to Retain Personal Possessions Violated
Penalty
Summary
The facility failed to ensure that a resident retained the right to use personal possessions, specifically a cell phone, which was taken away by the Administrator. The resident, who was dependent on a ventilator and had a tracheostomy, called 911 several times because she felt she could not breathe. However, she was unable to speak to the 911 operator and would hang up. The local police department contacted the Administrator about the repeated 911 calls, and the Administrator, concerned about the potential for the resident to receive a citation for abuse of the 911 system, took the phone away. The resident's family was informed of the situation, and they communicated with the resident via text to stop calling 911. The phone was returned to the resident within about 10 minutes. The facility's policy on resident rights states that residents have the right to retain and use personal possessions unless it infringes on the rights or health and safety of others. The report does not indicate that the resident's death was related to the removal of the phone.
Failure to Prevent Verbal Abuse of Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA, which was witnessed by the resident's family through a video camera in the resident's room. The incident occurred when the CNA attempted to force the resident to go to bed by grabbing the resident's arm and yelling, causing the resident to become angry. The resident, who has a history of dementia and schizophrenia, was resistant to going to bed and was looking for her purse, a common behavior before bedtime. The resident's care plan indicated that she had behavior problems related to her disease process, including fighting during showers, refusing assistance with ADLs, and refusing to go to bed at night. The care plan included interventions such as offering pleasant diversions, structured activities, and speaking in a calm manner. However, these interventions were not followed, and the CNA's actions escalated the situation, leading to verbal abuse. The incident was not reported by the LVN who assisted the CNA, as they did not perceive it as significant due to the lack of physical injury. The facility's abuse policy requires the reporting and investigation of all incidents of abuse, neglect, or mistreatment, but this protocol was not followed. The failure to report and address the incident promptly could place residents at risk for staff mistreatment.
Failure to Maintain Safe Bed Environment for Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident, who was legally blind and required supervision with bed mobility. The resident's bed was observed to be lopsided, which the resident reported as uncomfortable and causing sleep disturbances. Despite the resident informing the Maintenance Director about the issue, the bed remained in the same condition later in the day. The Licensed Vocational Nurse (LVN) acknowledged the bed's crooked appearance and recognized the potential risk of the resident falling off the bed. However, the Maintenance Director attributed the lopsided appearance to the resident's sitting position and weight distribution, rather than a defect in the bed frame or mattress. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of concern regarding the unevenness of the bed and headboard, with both stating there was no risk to the resident. The facility did not provide a policy on accident prevention, indicating a gap in their procedures for addressing environmental hazards. This oversight in maintaining the resident's bed and the absence of a formal policy on accident prevention contributed to the deficiency identified by the surveyors.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches within the premises. Observations and interviews revealed that residents had encountered roaches in their rooms, with one resident reporting a roach crawling on her bed and another resident witnessing roaches under the bed. Flies were also observed in a resident's room, particularly on a mattress with a yellowish-brown stain. The Maintenance Director acknowledged the presence of pests and stated that pest control services were conducted weekly, but urgent issues required immediate attention. Despite these measures, residents continued to report sightings of pests, indicating an ineffective pest control program. The facility's pest control records showed multiple reports of roach sightings in various rooms over several months, with specific entries detailing live roaches found during inspections. The Director of Nursing and the Administrator were unaware of the extent of the pest problem, as they had not received complaints or seen pests themselves. The facility's policy on insect and rodent control, dated 2012, was not effectively implemented, as evidenced by the ongoing pest issues and the lack of a comprehensive pest control policy beyond the food service department.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, as observed during a survey. Resident #5's nasal cannula was not bagged for sanitation when not in use, contrary to the facility's policy. Additionally, the resident's oxygen concentrator and filter were found to be contaminated with food crumbs, dust, and a spilled brown liquid. Despite being cognitively intact, Resident #5's care plan noted that she did not replace the nasal cannula in a bag when removing it, and it was sometimes found on the floor. Interviews with staff revealed inconsistencies in the maintenance and cleaning responsibilities for the oxygen equipment. Resident #16 also experienced similar issues with respiratory care. His nasal cannula was observed lying on the floor with the prongs touching the ground, and the oxygen concentrator was found with food crumbs and dust particles. The resident, who was cognitively intact, reported that staff did not bag the nasal cannula and he could not reach it when it fell. The facility's policy required nasal cannulas to be bagged when not in use, but this was not adhered to, leading to potential risks of respiratory infections. Interviews with nursing staff and the Director of Nursing (DON) highlighted a lack of clarity regarding the responsibilities for cleaning and maintaining the oxygen equipment. The facility's policy on oxygen administration did not address the storage of tubing when not in use, contributing to the observed deficiencies. The absence of a documented in-service training on respiratory care further indicated gaps in staff education and adherence to protocols.
Privacy Breach in Resident Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident, identified as Resident #1, who was severely cognitively impaired with a BIMS score of 02 and required maximal assistance with activities of daily living. During an observation via a Ring Camera, it was noted that a Licensed Vocational Nurse (LVN) and a male contractor entered the resident's room without closing the privacy curtain, leaving the resident exposed and naked. The resident's care plan indicated that the family preferred the resident not be clothed due to agitation, but the facility's policy on resident rights emphasized the need for dignity and privacy. The LVN admitted to not being familiar with the resident's treatment and care needs at the time of the incident and acknowledged the oversight in not closing the privacy curtain or covering the resident. The Director of Nursing (DON) did not respond to questions about the privacy breach, and the facility's policy underscored the importance of treating residents with respect and dignity. The incident highlighted a failure to protect the resident's privacy, as the LVN focused on locating an oxygen concentrator for the contractor, inadvertently exposing the resident to potential embarrassment.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) to Resident #33, specifically in ensuring regular showers or baths. Resident #33, a cognitively intact individual with a BIMS score of 14, has a primary diagnosis of Muscular Dystrophy and secondary diagnoses including quadriplegia, heart failure, and contractures. The resident is totally dependent on staff for showering, requiring the assistance of two staff members. Despite this, the resident reported not receiving showers for extended periods, including a three-week gap, and stated that staff often did not ask if she wanted a shower on her scheduled days. Interviews with facility staff, including a CNA and an LVN, confirmed that the facility tracks showers in an electronic medical records system and does not maintain paper logs. The staff described a system where residents in odd-numbered rooms are scheduled for showers on specific days, with A beds showered during the morning shift and B beds during the evening shift. However, the records showed that Resident #33 had only been showered twice in the last 30 days, with no documentation of refusals, corroborating the resident's account of inadequate showering. The facility's administrator confirmed that CNAs are responsible for showering residents and that refusals should be documented. The administrator expects staff to offer showers a second time if initially refused and to care plan for residents who repeatedly refuse showers. The facility's policy emphasizes the importance of bathing for hygiene and comfort, yet the lack of adherence to this policy resulted in Resident #33 not receiving the necessary care, potentially affecting her quality of life and self-esteem.
Failure to Document Ventilator Settings for Resident
Penalty
Summary
The facility failed to ensure that physician orders were written for ventilator settings for a resident from the time of their admission to the facility. This oversight was identified during a review of the resident's medical records, which revealed that there were no documented ventilator setting orders from the time the resident was readmitted to the facility. The resident, who was dependent on a mechanical ventilator, had a complex medical history including chronic respiratory failure, sepsis, pneumonia, and ALS. Despite the critical nature of the resident's condition, the necessary physician orders for ventilator settings were not documented, which could potentially compromise patient safety. Interviews with facility staff, including a respiratory therapist (RT) and the Director of Nursing (DON), revealed that the ventilator settings were known to the RT and were documented on the resident's flow sheet in the electronic medical record (EMR). However, the RT and DON both acknowledged that the admitting nurse should have placed the order for the ventilator settings upon the resident's return from the hospital. The RT stated that there was no risk to the resident because the ventilator settings were monitored and adjusted as needed based on the resident's vitals and oxygenation. The facility's administration, including the Administrator (ADM), expressed an expectation that orders should drive care and that nursing and respiratory staff should obtain the necessary orders for care. Despite this expectation, the facility was unable to provide a policy for physician orders when requested. The existing policy on medication orders emphasized the need for a current list of orders to be maintained in the clinical record of each resident, highlighting a gap in adherence to this policy in the case of the resident's ventilator settings.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Specifically, the facility did not ensure that a Licensed Vocational Nurse (LVN) disinfected a blood sugar monitoring device between uses on multiple residents. The LVN also failed to perform hand hygiene after removing gloves and handling the contaminated device. This oversight was observed during blood sugar checks for several residents, including those with diabetes and other serious health conditions. Additionally, the facility did not ensure that a Registered Nurse (RN) adhered to enhanced barrier precautions when administering G-tube medication to a resident. The RN did not wear the required personal protective equipment (PPE) and failed to perform hand hygiene before donning gloves. This resident had multiple health issues, including cerebral palsy and a history of urinary tract infections, which necessitated strict infection control measures. Interviews with staff revealed a lack of awareness and training regarding infection control procedures, including the sanitization of shared equipment and the use of PPE. The Assistant Director of Nursing (ADON) acknowledged the need for in-service training on these protocols, while the Director of Nursing (DON) and Administrator expressed expectations for staff compliance with infection control policies. The facility's policy emphasized the importance of hand hygiene as a primary means of preventing infection transmission, yet these practices were not consistently followed.
Fly Infestation in Dining Room Affects Residents
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the dining room, affecting three residents. Resident #66, a cognitively intact male with a history of stroke and other health issues, was observed with flies on his body while sitting in the dining room. He expressed discomfort and dissatisfaction with the presence of flies, which had been a problem for the past week. Resident #42, a male with severe cognitive impairment and multiple health conditions, was also affected by the fly infestation in the dining room. He expressed feeling like he was in a trash dumpster due to the flies. Observations noted that flies were present on 80% of the tables in the dining room, indicating a widespread issue. Resident #103, a female with moderate cognitive impairment and other health issues, was observed shooing flies away from her food while eating in the dining room. Interviews with staff revealed that the facility had a pest control program in place, with regular visits from a pest control company. However, the surrounding environment, including a barn, creek, and wooded area, posed challenges in controlling the fly population. The facility's pest control logs documented regular treatments for various pests, including flies, but the issue persisted, impacting the residents' dining experience.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #17 and Resident #114, were within their reach, which is a necessary accommodation for their needs. Resident #17, a female with a history of Covid-19, schizoaffective disorder, dementia, and multiple fractures, was found with her call light tucked underneath her fitted sheet, making it inaccessible. This resident had a recent fall resulting in multiple injuries, including fractures and a lip laceration, which occurred when she attempted to go to the restroom without assistance. The care plan for Resident #17 specifically required that her call light be kept within reach due to her fall risk. Similarly, Resident #114, a male with a history of cerebral infarction, dementia, and other conditions, was observed with his call light on the floor, out of his reach. This resident also required assistance with daily activities and had a care plan that mandated the call light be accessible to prevent falls and ensure he could request help when needed. Both residents were unable to locate their call lights when asked, indicating a failure in the facility's responsibility to accommodate their needs. Interviews with staff, including an LVN and a CNA, revealed that the call lights were not placed back within reach after linens were changed or other room activities were conducted. The facility's Administrator and DON acknowledged that it was the responsibility of nursing staff and other personnel to ensure call lights were accessible to residents. However, there was no existing policy in place to guide staff on maintaining call light accessibility, contributing to the oversight and potential risk to resident safety.
Privacy Breach Due to Unauthorized AEM in Shared Room
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information, specifically for a resident who shared a room with another resident. An AEM camera was observed in the shared room, capturing most of the room and the bed area of the roommate. The facility did not have signed consents from the roommates or their responsible parties in the active section of their electronic health records, which could lead to exposure of personal and medical information. Resident #18, a Hispanic male with a primary language of Spanish, was admitted to the facility with multiple diagnoses, including hemiplegia, alcohol-induced dementia, and type 2 diabetes. The resident had a BIMS score indicating severe cognitive impairment and required significant assistance with daily activities. Despite these conditions, there was no assessment for the ability to consent or any consent for AEM documented in the resident's records. Interviews with staff and the resident's responsible party revealed that the camera was placed without notifying the facility, and the responsible party was unaware of the need for consent from the roommate. The facility's staff indicated that if a roommate did not consent to AEM, they would attempt to move the resident to another room. However, there was no clear policy on audio recordings, and the facility lacked a designated person responsible for managing AEM consents.
Failure to Change G-Tube Tubing and Water Bag
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube (G-tube) received appropriate treatment and services according to professional standards. Specifically, the facility did not change the G-tube water and enteral administration set when the resident's formula was changed on two occasions. This oversight was observed during a survey, where it was noted that the water bag was not changed for several days, and the tubing was not replaced with the formula change, which could increase the risk of infection. The resident involved was a male with multiple complex medical conditions, including acute respiratory failure, bacterial infection, cerebral palsy, and dependence on respirator ventilation. He was completely dependent on staff for all activities of daily living and had a G-tube for nutrition. Despite these needs, the facility's care plan and order summary did not specify the requirement to change the tubing with each enteral feeding setup, nor did it reflect the need to change the enteral feed syringe every 24 hours. Interviews with nursing staff revealed a lack of adherence to proper procedures and a gap in training. One nurse admitted to not changing the tubing and water bag since a specific date, while another nurse acknowledged forgetting to change the tubing when adding a new formula bag. The Director of Nursing confirmed that the facility's policy required the tubing to be changed with every feeding change, but there was no clear monitoring process to ensure compliance. The facility's policies on enteral nutrition and infection control did not adequately address the replacement of tubing or dating of bags, contributing to the deficiency.
Failure to Manage PICC Line for Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically regarding the management of a Peripherally Inserted Central Catheter (PICC) line. The resident, a male with multiple complex medical conditions including hypotension, pneumonia, and dependence on respirator ventilation, was admitted with a PICC line. However, since admission, there were no orders to manage, access, flush, or perform dressing changes on the PICC line, which is crucial for preventing infection. Observations and interviews revealed that the nursing staff, including Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), were aware of the PICC line but failed to obtain necessary orders or perform required dressing changes. The Assistant Director of Nursing (ADON) and LVNs acknowledged the need for dressing changes and monitoring but did not take action to ensure these were completed. The PICC line dressing was not changed since the resident's admission, and there was a lack of clarity among staff regarding the policy for PICC line management. The Director of Nursing (DON) and other staff members confirmed that there were no specific orders for the PICC line, and the facility did not provide a policy for PICC/IV dressing changes. The Centers for Disease Control and Prevention guidelines recommend changing PICC line dressings every seven days to prevent infection, but this was not adhered to, placing the resident at risk. The deficiency was identified through a combination of record reviews, staff interviews, and observations, highlighting a significant lapse in the facility's adherence to professional standards of practice for IV fluid administration.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication carts and a respiratory treatment cart were securely locked when unattended, as observed on multiple occasions. On the morning of August 14, 2024, two medication carts and one respiratory treatment cart were found unlocked and unattended in various hallways. Specifically, Medication Cart #1 was left unlocked at the nursing station without any staff in view, and Medication Cart #2 was similarly unsecured in another hallway. The respiratory treatment cart was also found unlocked, facing outward in a hallway without staff supervision. Interviews with staff members, including LVNs and respiratory therapists, confirmed that the carts were supposed to be locked when not in use or under direct supervision. Staff acknowledged the potential risks of leaving the carts unlocked, such as unauthorized access to medications by residents or others. The facility's policy, as reviewed, clearly stated that medication and treatment carts must be locked when not in use or under direct supervision, highlighting a failure to adhere to established procedures.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure proper notification procedures were followed before transferring or discharging a resident to the hospital. Specifically, the facility did not send a written notice of transfer or discharge, along with the reasons for the transfer, to the Office of the State Long-Term Care Ombudsman for one resident. This oversight was identified during a review of the resident's records and interviews with facility staff and the resident. The resident, a female with chronic respiratory failure and other health conditions, was transferred to the hospital after experiencing shortness of breath and chest pain. Despite the transfer, the resident did not receive any paperwork indicating she had been discharged, and the ombudsman confirmed not receiving any discharge notifications. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for sending discharge notices, with different staff members providing conflicting information about their roles in the discharge process. The facility's policies require that a notice of transfer or discharge be provided to the resident, their representative, and the ombudsman, especially in cases of emergency transfers. However, the facility's administration and nursing staff did not adhere to these policies, resulting in the resident being discharged from the system without proper notification. The facility's failure to follow its own policies and procedures led to the deficiency identified in the report.
Failure to Provide Written Bed-Hold Policy Before Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold policy to a resident or their representative before the resident was transferred to a hospital. This deficiency was identified during a review of the case of a resident who was transferred to an acute care hospital. The resident, who had a history of chronic respiratory failure, candidiasis, chronic obstructive pulmonary disease, and required a tracheostomy, was not given written information about the duration of the bed-hold policy prior to her transfer. The facility's records showed that the resident was discharged to the hospital, and upon her readiness to return, the facility did not have a bed available for her. Interviews with facility staff, including the Marketing Manager, Administrator, and DON, revealed that the facility does not hold beds in the trach unit or general unit, and beds are filled as soon as they become available. The facility's admission packet indicated that bed-hold information should be provided at admission and re-issued at the time of transfer, but this was not done in the resident's case. The resident's family was informed to pick up her belongings, and the hospital social worker confirmed that the facility stated they had no bed available for the resident upon her medical clearance to return.
Failure in Tracheostomy Care Leads to Resident's Health Decline
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, leading to significant health issues. The resident, a male with a history of acute respiratory failure, tracheostomy status, and other medical conditions, was found to have a tracheostomy tube cuff that was chronically overinflated. This overinflation was not in accordance with the manufacturer's recommended pressure of a maximum of 25 cmH2O. As a result, the resident experienced remodeling of the T1 and T2 vertebrae and swallowing difficulties, which likely contributed to starvation ketoacidosis. Interviews and record reviews revealed that the facility's staff, including the Lead Respiratory Therapist, were aware of the resident's requests for additional air in the tracheostomy cuff. Despite knowing the risks, some staff members reportedly complied with these requests to avoid upsetting the resident. The facility's Director of Nursing (DON) and other staff members were unaware of the overinflation issue, and there were no specific physician orders regarding the pressure for the tracheostomy tube cuff. The resident's refusal to eat and other care refusals were documented, but the connection between the overinflated cuff and the resident's inability to eat was not recognized until the resident was hospitalized. The resident's condition deteriorated to the point of being found unresponsive and hypotensive, leading to hospitalization. Hospital records indicated severe malnutrition and other complications related to the overinflated tracheostomy cuff. Interviews with facility staff, including the DON, Lead RT, and the resident's physician, highlighted a lack of communication and oversight regarding the resident's tracheostomy care. The facility's policy on tracheostomy care did not address cuff inflation, contributing to the oversight and subsequent health issues experienced by the resident.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as observed during a survey. Resident #1, who required continuous respiratory oxygen therapy and CPAP use due to conditions such as acute respiratory failure and COPD, was found with undated oxygen tubing and a CPAP mask lying on the floor, unbagged and uncleaned. The resident's wheelchair, stored in the hallway, also had an oxygen tank with undated and unbagged nasal cannula tubing. These observations were made despite the resident's care plan indicating the need for careful monitoring and documentation of respiratory conditions. Similarly, Resident #3, who had severe cognitive impairment and required continuous oxygen treatment, was observed holding an undated nasal cannula, with additional tubing found on the floor, undated and unbagged. Resident #5, with moderate cognitive impairment and receiving oxygen therapy, had nasal cannula tubing wrapped around a bed rail and touching the floor, also undated and unbagged. Resident #7, who was cognitively intact and receiving oxygen treatment for COPD, was found with undated tubing connected to his oxygen concentrator and portable tank. Interviews with staff, including CNAs, RNs, and the ADON, revealed inconsistencies in the facility's practices regarding the dating, bagging, and changing of respiratory equipment. Staff acknowledged the importance of these practices for infection prevention but admitted to lapses in execution. The facility's policy did not mandate weekly tubing changes, instead requiring changes when tubing was visibly soiled or undated, which was not consistently followed, leading to potential risks of infection and inadequate respiratory care for the residents.
Failure to Update Resident Care Plan for Behavioral Changes
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan for a resident, which did not reflect the resident's current status and behaviors. The resident, a male with severe cognitive impairment and multiple medical conditions including acute respiratory failure, emphysema/COPD, atrial fibrillation, and dementia, exhibited behaviors such as not using the call light when needing assistance, removing his CPAP mask, and throwing both the call light and CPAP mask to the floor when agitated. These behaviors were not addressed in the care plan, which could place the resident at risk of not receiving appropriate care and interventions. The resident's care plan, dated earlier in the year, did not include interventions for the resident's behaviors related to the call light and CPAP equipment. Despite observations and interviews indicating the resident's inability to use the call light and his actions of disassembling the CPAP hose, the care plan remained unchanged. Interviews with the ADON and DON revealed that the staff was aware of these behaviors, but the care plan was not updated to reflect these changes, which could lead to inadequate care. The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans that address the resident's medical, physical, mental, and psychosocial needs. However, the failure to update the care plan for this resident indicates a lapse in following this policy. The DON acknowledged the oversight in updating the care plan, and the ADM was unaware of the resident's behaviors, highlighting a communication gap within the facility's staff regarding the resident's care needs.
Inaccessible Call Light Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible for a resident, which could place residents at risk of not receiving necessary care and services. Specifically, the call light for a resident was found on the floor and not within reach, despite the resident's care plan indicating the need for the call light to be accessible. The resident, who was severely cognitively impaired and required maximal assistance with activities of daily living, was observed to be agitated and stated that no one had come to help him out of bed. Interviews with staff revealed that the CNA was unaware of the call light being on the floor and mentioned that the resident often yelled for help instead of using the call light. The CNA also noted that the resident had a behavior of throwing the call light on the floor, but this behavior was not reported to the ADON or DON for further intervention. The charge nurse was also unaware of the call light's location and emphasized the importance of having the call light within reach for residents with confusion. The facility did not have a call light policy, and the DON and Administrator acknowledged the importance of residents being able to call for assistance in emergencies.
Delayed Reporting of Resident Fall Incident
Penalty
Summary
The facility failed to ensure the safety and well-being of Resident #1, who was found on the floor by Student Nurse Aide A during the 2:00 PM-10:00 PM shift on 04/09/24. Despite discovering Resident #1 on the floor at 9:46 PM, Student Nurse Aide A did not report the incident to the charge nurse until 4:40 AM the next day. This delay in reporting resulted in Resident #1 not receiving immediate treatment and care, including a nurse assessment, neurological checks, monitoring for possible serious injury, and timely physician notification. The resident, who had a history of dementia, diabetes, falls, and muscle weakness, was found to have significant bruising and injury to the right side of her face and head. The facility's failure to ensure proper protocols were followed when a resident was found on the floor led to a delay in necessary medical interventions for Resident #1. Despite having a care plan in place for fall prevention and interventions to ensure resident safety, the staff did not adhere to these guidelines effectively. The incident highlighted gaps in staff training and awareness, as evidenced by Student Nurse Aide A's lack of understanding of the appropriate actions to take when a resident is found on the floor. The subsequent interviews with staff members revealed confusion and miscommunication regarding the incident, indicating a breakdown in reporting and response procedures within the facility.
Failure to Implement Abuse/Neglect Policies Resulting in Delayed Care
Penalty
Summary
The facility failed to implement their written policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by the case of Resident #1. Student Nurse Aide A neglected to report to the charge nurse when she found Resident #1 on the floor, resulting in a significant delay in the resident receiving necessary treatment and care. This failure led to Resident #1 not being assessed by a nurse, not receiving neurological checks, monitoring for possible serious injury, and delayed notification to the physician. The facility's Abuse/Neglect policy clearly outlines the resident's right to be free from abuse and neglect, emphasizing the importance of timely reporting in cases involving abuse or serious bodily injury. Resident #1, an elderly female with a history of dementia, diabetes, falls, and muscle weakness, was found on the floor with significant bruising and injury to her face and head. Despite having a care plan in place to prevent falls and ensure resident safety, the failure of the staff to follow proper procedures resulted in Resident #1 being left unattended on the floor for an extended period. The facility's failure to ensure that staff members, especially Student Nurse Aide A, were adequately trained and aware of the correct protocols to follow in such situations directly contributed to the deficiency identified during the survey.
Inadequate Supervision Leads to Resident Elopement During Storm
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, a resident with severe cognitive impairment residing in the secure unit, leading to an incident where she wandered into the enclosed courtyard during a storm and was left outside for approximately 3 hours. Despite the resident's documented history of wandering behaviors and elopement risk, the facility did not adequately supervise her to prevent such incidents. The door leading to the courtyard, which required a code to open, was left unlocked or unsupervised when its locking mechanism lost power during the storm, allowing Resident #1 to exit without staff knowledge. This failure to provide adequate supervision put Resident #1 at risk of harm and exposed her to potential injury due to exposure to the elements. The deficiency was identified through a series of observations, interviews, and record reviews conducted by surveyors. Resident #1's medical history included diagnoses of dementia, diabetes, falls, hypertension, and muscle weakness, highlighting her vulnerability and need for close supervision. Despite the facility's care plan outlining interventions to prevent elopement, such as disguising exits, offering distractions, and closely supervising the resident, these measures were not effectively implemented in this instance. The incident report detailed Resident #1 being found lying on the ground in the courtyard, prompting a thorough investigation into the circumstances leading to her elopement.
Failure to Report Neglect and Delay in Treatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect were reported immediately, as required by regulations. Specifically, a student nurse aide found a resident on the floor but did not report the incident to the charge nurse. As a result, the resident did not receive immediate treatment and care until several hours later when another staff member discovered significant bruising and injury to the resident's face and head. The administrator also failed to report the incident to the appropriate state authorities after determining that the student nurse aide had neglected the resident by not notifying the charge nurse and placing the resident back in bed without an assessment. The resident involved was an elderly female with a history of dementia, diabetes, repeated falls, and other health issues. On the night of the incident, the resident was found on the floor by the student nurse aide, who then placed her back in bed without notifying the charge nurse. The resident was not assessed for injuries until the next shift, several hours later, when significant bruising and injury to her face and head were discovered. The delay in reporting and assessing the resident's condition resulted in a delay in treatment and care. Interviews with staff members revealed that the student nurse aide did not follow proper procedures for reporting falls and that there was a lack of communication between staff members regarding the incident. The facility's Director of Nursing (DON) and Administrator were aware of the incident but did not report it to the state authorities as required. The facility's policies on abuse, neglect, and reporting were not followed, leading to a deficiency in the care provided to the resident.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Oaks Health And Rehabilitation Center | 1.6 mi | — | 13 | 0 |
| Fort Worth Wellness & Rehabilitation | 2 mi | — | 0 | 0 |
| The Lodge Of Saginaw Health And Wellness | 3.5 mi | — | 12 | 0 |
| The Stayton At Museum Way | 4.3 mi | — | 3 | 0 |
| Trinity Terrace | 4.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.