MASON CREEK TRANSITIONAL CARE OF KATY
Government - Hospital district
125 Beds
THE ENSIGN GROUP
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
17/100
#771 of 1168 in TX
Photo by Mason Creek Transitional Care of Katy
Photo by Mason Creek Transitional Care of Katy
Photo by Mason Creek Transitional Care of Katy
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mason Creek Transitional Care of Katy has received a Trust Grade of F, indicating significant concerns about its care quality. Ranking #771 out of 1168 facilities in Texas places it in the bottom half of the state, and #62 out of 95 in Harris County, meaning there are many better options in the area. The facility's performance is worsening, with the number of issues increasing from 7 in 2023 to 9 in 2024. Staffing is rated average with a 3/5 star rating and a turnover rate of 48%, which is slightly better than the Texas average. However, the facility has reported serious incidents, including a failure to monitor a resident's oxygen levels during a shower, leading to a critical drop and the resident's eventual death, as well as an instance of physical abuse against another resident. While there is more RN coverage than 75% of facilities in Texas, the overall situation raises significant red flags for potential residents and their families.
- Trust Score
- F
- In Texas
- #771/1168
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $16,175 in fines. Higher than 76% of Texas facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
17/100
Bottom 34%
Review needed
7 → 9 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 7 issues
2024: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Texas average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near Texas avg (46%)
Higher turnover may affect care consistency
Federal Fines: $16,175
Below median ($33,413)
Minor penalties assessed
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 17 deficiencies on record
3 life-threatening
Dec 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 18 residents (Residents #66) reviewed for care plans.
Resident #66 did not have a care plan in place for the care and monitoring of her midline.
This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.
The findings included:
Record review of Resident #66's face sheet dated 12/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) dementia, abnormal weight loss, chronic kidney disease, constipation, dysphagia (difficulty or discomfort swallowing), cognitive communication deficit, acute osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and cystitis (inflammation of the bladder) .
Record review of Resident #66's admission MDS dated [DATE] revealed she did not have a BIMS score. Resident #66 was not admitted on antibiotics.
Record review of Resident #66's physician orders dated 12/2024 revealed on .Piperacillin-Tazobactam in Dex Solution 2-0.25GM/50ML dated 11/27/24 insert midline for IV tx for osteomyelitis dated 11/29/24. Resident #66 did not have physician orders to address the care or monitoring of the midline and bandage change.
Record review of Resident #66's care plan dated 11/2024 revealed I am on Piperacillin-Tazobactam in Dex Solution 2-0.25 GM/50ML Use 2.25 gram intravenously every 8 hours for sacral wound osteomyelitis for 6 Weeks via midline. Resident #66's care plan did not address the care or monitoring of the midline and bandage change.
Observation on 12/10/24 at 1:40PM revealed Resident#66 had a midline to her right arm. The date on the midline dressing read 11/30.
In an interview on 12/10/24 at 2:52 PM the MDS Nurse stated the DON initiated the care plans and the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change .
In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders.
In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON, she said the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes .
Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated revision/review date(s):1.2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional standards of quality care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 (Residents #66) of 1 Residents reviewed for peripheral intravenous care.
The facility failed to ensure Resident #66 had a physician order or care plan for the care and monitoring of her midline.
The facility failed to ensure Resident #66's midline dressing was changed every 7 days per facility policy.
The failures placed residents at risk of developing an infection.
Findings included:
Record review of Resident #66's face sheet dated 12/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) dementia, abnormal weight loss, chronic kidney disease, constipation, dysphagia (difficulty or discomfort swallowing), cognitive communication deficit, acute osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and cystitis (inflammation of the bladder).
Record review of Resident #66's admission MDS dated [DATE] revealed she did not have a BIMS score. Resident #66 was not admitted on antibiotics.
Record review of Resident #66's physician orders dated 12/2024 revealed on .Piperacillin-Tazobactam in Dex Solution 2-0.25GM/50ML dated 11/27/24 insert midline for IV tx for osteomyelitis dated 11/29/24. Resident #66 did not have physician orders to address the care or monitoring of the midline and bandage change.
Record review of Resident #66's care plan dated 11/2024 revealed I am on Piperacillin-Tazobactam in Dex Solution 2-0.25 GM/50ML Use 2.25 gram intravenously every 8 hours for sacral wound osteomyelitis for 6 Weeks via midline. Resident #66's care plan did not address the care or monitoring of the midline and bandage change.
Observation on 12/10/24 at 2:55 PM Resident #66's midline dressing change by LVN B revealed the midline site without redness, drainage, or swelling. During the dressing change, the nurse did not clean the site first with alcohol, instead cleaned with betadine first, cleaning the site back and forward, instead of starting at the site moving in a circle away from the site.
In an interview on 12/10/24 at 1:42 PM LVN B said after observing the dressing to Resident #66's midline read 11/30. LVN B said the dressing to the resident's midline was outdated. LVN B said he believed the midline dressing was supposed to be changed every 2 weeks, but he would have to confirm with the DON or the ADON. LVN B said it was important to change the resident's midline when it was due to be changed to prevent infection.
In an interview on 12/10/24 at 1:50 PM the DON said Resident #66's midline dressing was supposed to be changed every 7 days and PRN for infection control.
Interview on 12/11/24 at 3:26PM LVN B said he did not think he did well when changing Resident #66's midline dressing because he did not clean the resident site first with alcohol in a circular motion moving away from the site. LVN B said this was supposed to be done to avoid re-introducing bacteria to the site. LVN B said the site should have been cleaned with alcohol first and then betadine. LVN B said the last time he received an in-service on midline dressing change was about a year ago at another facility. LVN B said the ADON informed him that he had to clean the midline dressing site first with alcohol followed with betadine.
In an interview on 12/10/24 at 2:52 PM the MDS Nurse stated the DON initiated the care plans and the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change .
In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders .
In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON said, the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes.
In an interview on 12/11/24 at 2:33PM the DON said the ADON was also the Wound Care Nurse. The DON said LVN B had only been working at the NF for a few months. The DON said she completed training with LVN B on midline dressing changes with return demonstration. The DON said when cleaning the site of the midline, the nurse was supposed to clean the site with alcohol first to ensure the skin was clean and then clean with betadine/iodine for infection control.
Record review of the Nursing facility policy on Midline Dressing Changes/Intravenous Therapy dated 08/30/2024 revealed in part:
.The purpose of this procedure is to prevent catheter-related associated with contamination, loosened or soiled catheter-site dressings .Change midline catheter dressing every 7 days, or if it is wet, dirty, not intact, or compromised in any way .use aseptic technique when changing a midline catheter dressing .If using alcohol and iodine packages .use alcohol swabs first. Clean in concentric circles away from the catheter .Repeat the same process with iodine swabs. Do not remove iodine from the skin .
Record review of the Nursing facility policy Physician Orders dated 11/13/18 revealed in part:
It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures) only upon written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care 6. Medication, treatment, or related orders are transcribed in the eMAR, eTAR accurately and verified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services that assured the ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and administering medications for 1 (Resident #78) of 8 residents reviewed for pharmaceutical services.
-Medication Aide A failed to administer the correct dosage for Resident #78's transdermal nicotine patch.
-Medication Aide A failed to rotate the transdermal nicotine patch on Resident #78's body.
This failure placed the resident at risk for skin irritation and not receiving the full intended therapeutic dosage of the medication.
Findings:
Resident #78
Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with the diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure).
Record review of Resident #78's admission MDS dated [DATE] reflected a BIMS score of 13 indicating that resident cognition was intact.
Record review of Resident #78's December 2024 Physician Oder Summary Report reflected the following order:
-Dated 11/13/24 Nicotine Patch 24-hour 14mg/24HR apply 1 patch trans-dermally (medication that is absorbed through the skin into the blood stream) one time a day for smoking cessation and remove per schedule.
Record review of Resident #78's MAR for the month of December 2024 reflected that the resident was being administered mediations per physician orders.
Record review of Resident #78's Comprehensive Care Plan dated 10/23/24 reflected that the resident was being care planned for refusing rotation of the nicotine patch date initiated 12/12/24 that included the following interventions:
-Allow to make decisions about treatment regimen, to provide sense of control.
-Educate resident/family/caregivers of the possible outcome (s) of not complying with treatment or care.
-Encourage resident to comply with rotation of nicotine patch to minimize risk of skin irritation.
Observation on 12/10/24 at 9:38AM of Medication Aide A administered the medication nicotine transdermal patch 7mg to Resident #78. Medication Aide A removed the old patch on the resident's left upper arm and placed the new patch on the same area of the resident's left upper shoulder.
In an interview on 12/12/24 at 10:30AM Medication Aide A said she made a mistake when administering Resident #78's nicotine patch by not administering the correct dosage. Medication Aide A said she administered to the resident 7mg instead of the ordered dose 14mg. Medication Aide A said it was important to rotate the resident's nicotine patch to avoid the risk of skin irritation. Medication Aide A said the reason she did not rotate the resident's nicotine transdermal patch was because the resident refused for it to be rotated. Medication Aide A said because she did not administer the correct dosage, the medication would not be as effective. Medication Aide A said she made a mistake. Medication Aide A said the 6 rights to use when administering medications were the following: the right patient, right medication, right dosage, right time, right route, and right order. Medication Aide A said the last time the pharmacist was at the facility, it was approximately a week ago, and observed her during medication pass.
In an interview on 12/12/24 at 11:40AM the DON said the reason the medication patches should be rotated was to avoid any skin irritation. The DON said she would be conducting a medication in-service with Medication Aide A. Further interview with the DON, she said it was herself and the other ADON's that observed medication passes with the nursing staff and that the pharmacist came to the NF once a month to observe medication pass along with checking the medication carts. The DON said she just learned that Resident #78 was refusing for his nicotine transdermal patch to be rotated. The DON said she would provide a copy of Medication Aide A training and her last medication observation.
Record review of Medication Aide A last observation of medication pass signed by the DON on 11/06/24.
Interview on 12/12/24 at 2:26PM with Resident #78 said he never refused for his nicotine transdermal patch to be rotated. The resident said he did not have any problems with the staff rotating his patch on his body.
Record review of the NF policy on Medication Administration---General Guidelines revised 11/13/18 reflected in part:
.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, the nurse/medication aide will verify the MAR with the order in the medical record .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 residents (Resident #78 and Resident #777) of 8 residents reviewed for infection control.
-Mediation Aide A failed to sanitize blood pressure equipment after taking Resident #777's blood pressure. Medication Aide proceeded to take Resident #78's blood pressure.
This failure placed the residents at risk for cross contamination, infections, and a decrease in quality of life.
Findings:
Resident #777
Resident #777 was a [AGE] year-old male admitted to the NF on 11/30/34. Resident #777's diagnoses included the following: hypotension (low blood pressure), dementia (memory loss and judgement), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and hypertension (high blood pressure).
Resident #78
Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure).
Observation on 12/10/24 during medication pass at 9:15AM of Medication Aide A taking Resident #777's blood pressure that was 122/79 and heart rate was 63. After taking Resident #777's B/P, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment.
Observation on 12/10/24 at 9:23AM Medication Aide A went to Resident #78's room and took his B/P with the same B/P equipment with a blood pressure reading of 178/86 and heart rate of 63. When done, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment.
In an interview on 12/10/24 at 9:40AM Medication Aide A said she was supposed to sanitize resident care equipment after each use to prevent cross contamination and infection control. Medication Aide A said she forgot to sanitize the blood pressure equipment.
In an interview on 12/10/24 at 1:50PM the DON said the staff were supposed to sanitize all resident care equipment to prevent cross contamination and infections.
Record review of the NF policy on Infection Control Prevention & Control Program revised 12/2023 revealed in part:
.The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .Reporting mechanisms for infection control .Effective and disinfecting equipment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed:
- A roach was o...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed:
- A roach was observed on a wall in the kitchen where food was being prepared for residents.
These failures could place residents at risk for infections.
The findings included:
In an observation on 12/10/2024 at 11:39 AM, while [NAME] B was preparing soft mechanical food a semi-large roach crossed the wall in front of her and went behind a food mixer on the counter less than an arm's reach away.
In an interview on 12/10/2024 at 11:39 AM, [NAME] B stated that she seen the roach on the wall while preparing food. She stated that she had seen roaches in the kitchen, but not a lot. She stated she last saw a roach about 1.5 months ago. She stated that when she saw pests in the kitchen, she informed the DM who informed maintenance.
In an interview on 12/10/2024 at 11:41 AM, the DM stated that she had seen the roach on the wall while [NAME] B was preparing food. She stated that pest control services the kitchen every 2-weeks. She stated that the facility just switched to a new pest control company because the previous company's services were not working.
In an interview on 12/10/2024 at 12:25 PM, DM, stated that she kept her kitchen clean, and maintenance was informed of the pest sighting in the kitchen. She stated that importance of reporting pests to maintenance was to keep the kitchen free of rodents and maintain infection control.
In an interview on 12/12/2024 at 02:14 PM with the OM he stated they just switched pest control companies and the new company just serviced the kitchen on 12/11/2024. He stated when they learned of a roach siting on 12/10/2024, the FMD called the pest control company, and they came out. He stated there have not been any further pests siting since 12/10/2024 in the kitchen. He stated that all facility staff know to contact the Facility Maintenance Director (FMD) and report pest control issues to him immediately. He stated that residents' health and safety could be impacted if they failed to address pest control issues.
In an interview on 12/12/2024 at 02:21 PM, the FMD stated that he had been with the facility for 18-years. He stated that they have a new pest control company servicing their pest needs. He stated that the previous company only laid pest compound on the outside of the facility. He stated the previous pest company told them their chemicals were not safe for indoor use and could harm the residents if they came into contact. He stated he had received reports of roaches, spiders, and tiny sugar ants and knew the company's product was not working. He stated as a result, they switched back to their original company about a month ago and they had not had any pest sightings since. He stated that clinical staff reported pests' issues to him directly or by adding it to a maintenance logbook kept at the nurse's station. He stated he checked the book twice a day, once in the morning and once in the evening. He stated the non-clinical, housekeeping staff sometimes reported issues to him through the facility communication app, whenever they seen any pests in the rooms. He stated whenever sightings were reported, he called the pest company to come out and spray immediately. He stated the facility also had an in-house pest chemical they used to spray. He stated the issues began when residents admitted with their own personal mini refrigerators. He stated that refrigerators are roach magnets. He stated that he had made it procedure that when new admissions admitted with refrigerators, they were to be placed out back for his inspection prior to being placed in the room. He stated that the admission team were aware of the procedure and were in full compliance. He stated he conducted an in-service on pest control at the facility's last all staff meeting, which he could not recall the date or time. He stated not addressing pest issues would be unsafe for the resident's health, and residents would not want pests near them.
In an interview on 12/12/2024 at 03:26 PM, LVN H stated she works the 1st shift at the facility since May of 2024. She stated that she had not become aware of any pest control issues in the facility and had she, she would immediately report to FMD. She stated that the facility provided an in-service on pest control about a month ago.
In an interview on 12/12/2024 at 03:32 PM, CNA R stated she works full-time, PRN for the facility. She stated that she had seen some roaches in the employee breakroom about 4-weeks ago and immediately reported the issue to the FMD. She stated that she received an in-service 2-weeks ago on pest control.
Record review of pest service report dated 11/19/2024 and 12/05/2024, revealed that the facility was serviced for pest control in the interior and exterior areas and finding zero pest activity.
Record review of facility in-service dated 12/10/2024 at 01:00 PM, with the dietary department revealed Report all rodent issues to manager, if manager not available report to assistant. Manager will report to maintenance. Recommendations/follow-up: maintenance were notified. Conducted by the DM.
Record review of undated facility policy titled: Pest Control Policy/Procedure revealed: Subject: Pest Control. Policy: It is the policy of this facility provide an environment free of pests. Procedures: 1. The facility will have a pest control vendor contract that provides treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's state. 5. Pest control problems will be reported prompt.
Tag:
S/S=
Surveyor Name(s):
Immediate Supervisor:
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen...
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Based on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.
- The facility failed to ensure food was labeled and dated.
- The facility failed to ensure that food was off the floor in the dry food area.
These failures could place residents who ate food from the kitchen at risk of food borne illness and disease.
Findings Included:
Observation on 12/10/2024 at 08:53 AM, revealed in 1 of 1 walk in refrigerator a metal bowl with clear plastic wrap with a with no date or item description. [NAME] B took the bowl out of the refrigerator.
Observation on 12/10/2024 at 08:56 AM, revealed on the floor of 1 of 1 walk in pantry a 24-ounce (oz), less than a 25 precent (%) full bottle of syrup dated 3/17 between 1 of 3 shelves on the right side of pantry and an 1-oz bag of chips was observed on the floor between the shelves near the wall. [NAME] A removed the syrup and bag of chips from the dry food storage area.
Observation on 12/10/2024 at 08:59 AM, revealed 1 of 1 standalone refrigerator had 9-glasses of milk with lids sitting on a tray with no label.
In an interview on 12/10/2024 at 08:50 AM, [NAME] A stated that he would oversee the kitchen until the Dietary Manager (DM) came on shift, and she would be on her way. During the initial tour of the kitchen in 1 of 1 walk-in refrigerator, [NAME] A stated he was not aware of what was in the metal bowl. He turned to [NAME] B and asked what was in the bowl. [NAME] A stated he had not seen the syrup on the floor in the dry food storage areas. He stated he does not know how long the syrup could have been there. When asked could it have been there since March 17th of this year, he stated it could have, but if he had seen it, he would have gotten it up. He stated he was not aware of how long the bag of chips were on the floor.
In an interview on 12/10/2024 at 08:53 AM, [NAME] B stated that the food item in the metal bowl was beef tips she had been marinating from a left-over dinner. When asked what day the beef tips were prepared, [NAME] B stated, the other day. When asked why they were in the refrigerator undated, she stated that she would throw them out.
In an interview on 12/10/2024 at 08:56 AM, [NAME] A stated that the milk in the 1 of 1 standalone refrigerator was poured the night before in preparation for the morning meal. He stated that he there was a label on the milk tray. [NAME] A looked but could not find a label. [NAME] A stated there should have been a labeled on the tray so that they knew when the milk was old and should not be served to residents that would make them sick. [NAME] A stated that the label was on a tray in the dish area and he had just changed out the trays after milk had spilled on the tray.
In an interview on 12/10/2024 at 12:25 PM, Dietary Manager (DM), stated that the meat in the metal bowl were beef tips, prepared for residents on 12/08/2024. She stated that food not prepared and not cooked was only to be stored for 3-days and thrown on the 3rd day. She stated that 12/10/2024 was the last day for the food to be stored and it was to have been thrown away. She stated it was her expectation when there was left over meat from a meal that it be thrown away the same day. She stated that [NAME] B told her that the beef tips were saved to serve as an alternative meal if needed, and the date and description of the item was written on the label. She stated that 12/10/2024 was the 3rd day and the day the item would have to be thrown away. She stated that she was not aware of the items on the floor in the dry storage area. She stated that [NAME] A told her that he was in the process of relabeling the milk when the State surveyor entered the kitchen and had not relabeled the milk tray because he toured the kitchen with the surveyor. She stated it was her expectation that no interrupt should deter staff from labeling food items and all food items were to be labeled before storing. She stated it was also her expectation if staff saw food items on the floor that they would immediately throw them away. She stated the importance of labeling food was to ensure that residents were not served outdated or expired food that could make them sick. She stated that importance ensure food items were off the floor were to ensure that residents were not served contaminated and expired food that would make them sick and to ensure not to attract pests.
In an interview on 12/12/2024 at 02:14 PM, with the DON and Operations Manager (OM) the OM stated that all food should be labeled to know when the items expired, and to know when it would expose danger to residents. The DON stated failure to label could cause the food not to taste good and make the residents sick.
Record review of facility menu dated Saturday, Week 1, revealed that braised beef tips with gravy were served for lunch (12/07, 2024).
Record review of facility in-service dated 12/10/2024 at 01:00 PM, with the dietary department revealed: Staff make sure no chip, or item are on dry storage floor. If there is, please put in the trash immediately. Do not put back on shelf.
Record review of facility policy titled Control Policy/Procedure and dated 08/2007, revealed: Section: Dietary Services Subject: Food Storage POLICY: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. PROCEDURES: 2. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times.
Nov 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Notification of Changes
(Tag F0580)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and interview, the facility failed to immediately consult with the resident's physician when th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and interview, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 9 residents (CR #1) reviewed for change of condition.
The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy just after breakfast on [DATE]. At approximately 3:00 p.m., CR #1 experienced a drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53% after a shower and resulted in loss of consciousness, initiation of CPR, and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). CR #1 expired on [DATE] on hospice at his home.
An IJ was identified on [DATE] at 2:52 p.m The IJ template was provided to the facility on [DATE] at 2:52 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE].
This failure placed residents who experience a change of condition at risk of worsening of condition and possible death.
Findings include:
Record review of CR #1's face sheet, dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] from an acute care hospital. He was diagnosed with UTI (an illness in any part of the urinary tract), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), aphasia (a language disorder that affects a person's ability to communicate), acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when there is too much carbon dioxide in your body. It can happen all at once [acute] or come on over time [chronic]), and essential hypertension (a form of hypertension without an identifiable cause). CR #1 was discharged to an acute care hospital on [DATE].
Record review of CR #1's MDS dated [DATE] revealed he was admitted from an acute care hospital on [DATE].
Record review of CR #1's BIMS dated [DATE] at 2:55 p.m. revealed he had a score of 0 (severe cognitive impairment).
Record review of CR #1's Functional Abilities admission Assessment dated [DATE] revealed, MDS Reason for Evaluation: Admission/5-Day . Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury - Independent - Resident completed all the activities by themselves, with or without an assistive device, with no assistance from a helper . Prior Device Ise - Manual Wheelchair, [NAME] .
Record review of CR #1's care plan dated [DATE] revealed the following care area:
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ADL Self Care Performance Deficit. Goal included: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with modified independence. Interventions included: Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders; Toilet Use: requires assistance; Transfers (Chair /Bed to Chair Transfer, toilet transfers: Requires staff participation with transfers; Bed Mobility: Requires staff participation to reposition and turn in bed; Encourage to participate to the fullest extent possible with each interaction; Bathing (Shower/Bathe Self): Staff will provide the required assistance needed for bathing; Personal Hygiene/Oral care: Staff will provide the required assistance needed for personal hygiene/oral care; Dressing: Requires staff participation to dress; Eating: Staff will provide the required assistance needed for eating as needed.
Further review of CR #1's care plan revealed no focus/care area related to his respiratory condition or oxygen requirements/needs.
Record review of CR #1's preadmission hospital records dated [DATE] revealed he was admitted to a local acute care hospital on [DATE] for weakness and was diagnosed with complicated UTI (any UTI that is not considered simple, and defined by the presence of underlying conditions rather than the severity of the infection), acute on chronic respiratory failure with hypoxia, acute toxic metabolic encephalopathy (a condition that causes global cerebral dysfunction, resulting in altered consciousness, behavior changes, and seizures), acute diarrhea due to E.coli (diarrhea caused by bacteria), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary fibrosis (a condition in which the lungs become scarred over time), acute on chronic congestive heart failure (a type of heart failure that occurs when the heart has difficulty compensating for a loss of function that has developed over time) and history of CVA (a stroke; when blood flow to the brain is suddenly cut off) with global aphasia (a severe form of non-fluent aphasia caused by damage to the left side of the brain). The document read in part, . [CR #1] is a [AGE] year-old male with pulmonary fibrosis who was hospitalized for metabolic encephalopathy and atrial fibrillation with rapid ventricular response due to complicated UTI and infectious diarrhea. Patient improved with supportive measures including antibiotics and rate control. Patient was discharged in stable cardiology and pulmonology for continued evaluation and management as outpatient . Review of Systems . Respiratory: Negative for cough, shortness of breath, and wheezing . Respiratory/Pulmonary Interventions Documentation: . Respiratory Quality/Sounds: Dyspnea (shortness of breath) on exertion, dyspnea laying flat, dyspneic (having difficulty breathing or being unable to breathe without effort), tachypneic (fast breathing) . Respiratory/Pulmonary Interventions: O2 Delivery Method: Nasal cannula; O2 flow rate (L/min): 5 L/min . [DATE] . History of Present Illness . He was on baseline O2 of 4-5 L/min . Patient was admitted for further evaluation . He developed episode of a-fib and SOB/cough overnight, given breathing treatments and IV metoprolol (a medication used to treat high blood pressure, chest pain, and heart failure) . Currently he is resting in bed, no acute distress. On 6L/min via nasal cannula . Pulmonary and Critical Care Consult Note, [DATE]. Assessment: Chronic hypoxic respiratory failure with home oxygen dependence between 4 to 6 L/min at baseline, 8L with exertion . Pulmonary Progress Note: [DATE] . Patient states his breathing feels comfortable at his baseline oxygen requirement of 5L/min . He has been saturating at 100% .
Record review of CR #1's Initial admission Record dated [DATE] revealed LVN C wrote . Most Recent O2 saturation: 98% ([DATE] at 5:15 p.m.) Method: oxygen via nasal [cannula] . General Skin Condition: Normal - Yes, Pale/Ashen - No, Flushed - No, Cyanotic (bluish or purple discoloration) - No . Pulmonary System. Diagnosis: Does the Resident have a Pulmonary Diagnosis - No . Pulmonary System. Oxygen. Oxygen Use - No .
Record review of CR #1's physician's orders for [DATE] revealed:
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Check and record O2 Saturation every shift. Order Date: [DATE]. Start Date: [DATE].
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O2 at 2-4 L/Min Continuous per nasal cannula every shift. Order Date: [DATE]. Start Date: [DATE]
Record review of CR #1's MAR for [DATE] (there was no MAR for [DATE]) revealed:
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Check and record O2 Saturation every shift. There were no entries for this order. CR #1 was hospitalized .
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O2 at 2-4 L/Min Continuous per nasal cannula every shift. There were no entries for this order. CR #1 was hospitalized .
Record review of CR #1's progress notes for [DATE] revealed:
On [DATE], LVN D wrote, At 5:15 p.m., patient arrived as a new admit to the facility via wheelchair with belongings . O2: 98% 5L of O2. NP notified of admit and verified orders and lab orders for CBC and BMP.
Record review of CR #1's progress notes for [DATE] revealed:
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On [DATE] at 1:57 p.m., LVN E wrote, COC for CO2 of 45 (normal range 21.0 - 31.0). Resident has a critical lab of CO2 45, NP informed and awaiting new orders.
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On [DATE] at 6:08 p.m., LVN E wrote, Resident had just finished taking a shower when the CNA [CNA B] brought out the resident from the bathroom looking weak but breathing. This nurse told the CNA to take resident back to his room. Later this nurse was called by CNA that resident is not looking good. This nurse did a sternal rub (a painful stimulus used to assess a patient's neurological status and responsiveness) on patient and observed that the patient was still unresponsive and had a weak pulse. This nurse told CNA to call code blue. Patient was then transferred from shower chair to bed. Chest compressions began immediately. Staff members rushed in with crash cart at bedside and placed back board underneath. Another staff called 911, while using the non-rebreather to deliver oxygen. Another staff focused putting in a peripheral IV line for fluid. Blood sugar was checked. O2 sat 58% according to pulse oximetry. Resident started moaning and moving his lower extremities just before 911 ambulance arrived to take over. Resident was later taken to the hospital.
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On [DATE] at 11:28 a.m., the DON wrote, IDT met to discuss [CR #1]. During review, it was noted that resident's order for O2 2-4LPM was incorrectly typed and should have been 2-5LPM as resident order verified for 2-5LPM upon resident admission with NP. Resident admitted 10/31 at approximately 5:15 from hospital on 5L of O2 [saturating] at 98% with diagnosis of Pulmonary Fibrosis, UTI, Aphasia . On 11/1, resident participated in physical therapy, speech therapy, and occupational therapy. During therapy session, resident was on 5L of oxygen and oxygen was monitored throughout session and remained between 86% and 95% on 5LPM per NC. Later in the day, around 3:00 p.m. resident was taken for a shower. Resident was taken to the shower with oxygen and remained on oxygen therapy throughout the duration of the shower. Shower CNA [A] stated that during his shower, he had his oxygen on, and was alert throughout the course of his shower. Towards the end, resident began to appear weak. CNA [A] called to CNA [B] to come assist. When CNA [B] was transferring the resident back down to his room, resident began to slump in his chair. CNA [F] assisted with getting resident to the room and called to the nurse for assistance with family at bedside. When the nurse arrived at the room, resident was unresponsive to stimuli, RN [E] called code blue and CPR was initiated. Oxygen was changed from NC to NRB and [O2] sat noted to be at 58%. 911 was called by other staff. When EMS arrived, resident had pulse and was responsive.
Record review of CR #1's PT Evaluation and Plan of Treatment completed by the PT and dated [DATE] revealed, . Cardiopulmonary Assessment - At rest: . Oxygen saturation: 98 (on 5 L). Activity: Patient's rated/reported level of exertion = Patient is unable to communicate exertion felt during activity. Oxygen saturation with activity: 86 [%](on 5L) .
Record review of CR #1's EMS records dated [DATE] revealed, . Call Received: 3:51 p.m. On Scene 3:59 p.m.Depart Scene: 4:41 p.m. Chief Complaint: Patient is a [AGE] year-old male with complaints of unconscious and respiratory distress. Patient is unconscious, cannot sit up and cannot ambulate with assistance . History: The issue with cardiac arrest began more than 5 minutes ago . Treatment (Plan): Stopped CPR and found spontaneous pulses and irregular respirations . SPO2 (4:06 p.m.: 89%), (4:16 p.m.: 96%) .
Record review of CR #1's hospital records dated [DATE] revealed he was transferred from the facility to the ER then ICU of a local acute care hospital on [DATE]. He was intubated and was diagnosed with cardiac arrest (when the heart suddenly stops beating). The document read in part, . Brought in by EMS [from facility]. CPR in progress upon EMS arrival, staff was doing compressions. Patient was moving around and had a pulse but decreased respiratory effort . Physical Exam ([DATE]) General: He is in acute distress. Appearance: He is ill-appearing . Pulmonary: Patient is having assisted ventilation . Neurological: Unresponsive .
Observation and interview with CR #1 on [DATE], at 2:45 p.m. revealed he was in the ICU at a local acute care hospital. CR #1 was intubated and opened his eyes to verbal stimuli. CR #1 did not attempt to communicate or make any gestures unless a family member spoke to him. There were multiple family members present at that time. Two family members stated they were present at the facility when CR #1 was admitted to the facility on [DATE]. Both family members stated they informed staff at the facility they would have to increase CR #1's oxygen to 6 - 8 L/min while he was in the shower as they had to do at home. The family members stated the DON told them staff had equipment in the shower to monitor CR #1's oxygen. One family member said CR #1 was able to tell them he remembered being at the facility, but he could not recall what happened in the shower. Another family member who only spoke Spanish (translated by an English speaking family member) stated CR #1 complained about the oxygen in that place and he told her through nodding and gestures that he did not have what he needed. CR #1 did not answer questions at that time.
In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted on [DATE] and was sent out on [DATE] when he coded in respiratory/cardiac arrest around 4:00 p.m. She said CR #1's oxygen saturation dropped significantly, and he was non-responsive. She said CR #1 received therapy on [DATE] and then he was taken to the shower. The DON said while CR #1 was going back to his room, he became week and then became unresponsive. She said CR #1 was on continuous oxygen and had it on the whole time he was in the shower. She said she investigated the incident after CR #1 was discharged to the hospital on [DATE]. She said CR #1 never went without his oxygen while he was at the facility. She said he transferred from the hospital on [DATE] on 5 L/min of oxygen. She said she verified with the nurses, CNA's and therapist that CR #1 was always on 5 L/min. The DON said she would have gotten a physician's order for more oxygen, but CR #1 was tolerating 5 L/min during exertion (she did not specify which exerting activities). She stated throughout CR #1's time in therapy, he remained between 86% and 95% oxygen saturation (according to the American Lung Association, dated [DATE], a person with pulmonary fibrosis should maintain an oxygen saturation level above 90% throughout the day and night). She stated that level was good given his diagnosis of pulmonary fibrosis. She stated when CR #1 went into distress, his oxygen saturation level was 58% on a non-rebreather (a medical device that delivers a high concentration of oxygen). She stated she spoke with CR #1's family and she told them all of CR #1's orders from the hospital indicated he should have been on 2 - 4 L/min of oxygen, but up to 5 L/min if in distress. She stated CR #1 could not walk, he was aphasic, but was alert and aware. She said CR #1 remained alert in the shower until staff transferred him back to his room in a wheelchair.
In an interview with CNA A on [DATE], at 11:20 a.m., she stated she worked at the facility as a shower aide. She stated she only interacted with CR #1 one time ([DATE]). She said she had never seen CR #1 before he was brought to her in the shower room on [DATE]. She said the assigned CNA brought residents to the shower room and went back to pick them up after their shower to go back to their rooms. She said when CNA B brought CR #1 to the shower room, he was on oxygen via nasal cannula and in a shower chair. She said she tried to communicate with CR #1, but he did not really talk. She said CR #1 may have said some words, but they were in Spanish. She said CR #1 was not breathing heavily or abnormally. She said CR #1 seemed to be weak. She said during the shower, she did all the work, other than raising his arm when she asked him to. She said she was in the shower alone with CR #1 until CNA B came back to get him. She said she only looked at CR #1's portable oxygen tank when he initially arrived at the shower room, and he was on 5 L/min. She said she had to carry the portable tank and she saw 5 L/min and it was full. She said she carried the tank over to where she dried and dressed CR #1. She said the only time she noticed a change in CR #1 was when CNA B looked inside the door after he was dressed. She said she told CNA B that she did not think CR #1 looked too good. She said CR #1's color changed, and he looked pale to her. She said CR #1's breathing was the same (normal) and he was sitting straight up in his chair, not slumped over. She said all CNAs were trained to recognize changes of condition, including respiratory distress. She said the only way she could have known if CR #1's oxygen was on was if she checked the nasal cannula to see if air was coming out because the oxygen did not make sound. She said she did not check CR #1's oxygen after the shower started.
In a telephone interview with CR #1's family member on [DATE], at 11:32 a.m., she stated CR #1 was currently in the ICU and the family was asked to place him on hospice (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). She said when she spoke to the facility's DON after CR #1 was transferred to the hospital, she said maybe the hospital discharged CR #1 before he was ready. She stated CR #1's oxygen never decreased (desaturated) as low as it did on [DATE]. She said CR #1 was almost unresponsive when he returned to his room, and she wanted to know how he got to that point because it never happened before. She said CR #1's oxygen levels were never an issue at the hospital prior to his admission to the facility. She stated the hospital doctor told her that CR #1's oxygen level went too low, and his body shut down and it looked like cardiac arrest. She said CR #1's baseline oxygen requirement was 4 L/min at rest and 6 - 8 L/min with exertion. She said CR #1 had therapy on Friday, [DATE] and the therapist told her they had to increase his oxygen while in therapy. She said she informed the admitting nurse on Thursday, [DATE], and the therapist on Friday, [DATE] they would have to increase CR #1's oxygen to 6 - 8 L/min on exertion, including walking and showers. She said the DON told her CR #1 was on 4 L/min when they took him to the shower. She said another family member was in CR #1's room on [DATE] when staff took him to the shower. She said the other family member said they were in the shower for 30 minutes and when CR #1 returned to his room, he was slumped over and unresponsive.
In an interview with the PT on [DATE], at 12:15 p.m., she stated she evaluated CR #1 on [DATE] and she did not know he was transferred to the hospital until [DATE]. She said she went to CR #1's room on [DATE] to evaluate him for physical therapy and occupational therapy right after breakfast. She said when she arrived at his room, he was in bed with oxygen on via nasal cannula. She stated CR #1 was aphasic and was not able to verbalize, but he used gestures and pointed to things to communicate. She stated he did speak in a mix of broken Spanish and English and he was able to follow directions. She said she worked with CR #1 on walking from the bed to the bathroom door, about 10-12 feet. She said CR #1 did alright, but she noticed he was exhibiting signs of SOB, so she checked his oxygen. She said she could not recall what CR #1's oxygen saturation was. She said she instructed CR #1 to breath properly and deeply. She said CR #1 followed instructions and his oxygen saturation went up without increasing his oxygen. She said she assisted CR #1 back to bed and told him he would start therapy. She said she told his nurse (RN E) CR #1's oxygen saturation decreased when she walked him, so the nurse was aware. She said she wanted to get information about CR #1's baseline, so she called his family member. She said CR #1 was already breathing heavily when he was lying down before therapy because she could see his chest and stomach rise and fall. She said CR #1 was on 5 L/min of oxygen according to his physician's order. She said when she called CR #1's family member after the evaluation, the family member mentioned that at home, he was on 5 L/min. She said she did not increase CR #1's oxygen during the evaluation because she did not have the authority to do that, and he was fine after doing proper breathing exercises.
In a telephone interview with CR #1's NP on [DATE], at 12:57 p.m., she stated CR #1 admitted on [DATE] after she had already completed rounds at the facility, so she never met him. She stated she did not recall speaking to anybody regarding his medications, so staff must have verified his physician's orders with the on-call physician. She stated it was hard to say if 1 L/min of oxygen would have made a difference for CR #1. She said with his history of pulmonary fibrosis, usually a higher oxygen level did not guarantee better perfusion of lungs. She said she did receive a report that CR #1's blood pressure was slightly low (she could not recall when she received this report), so she called the DON to go assess and recheck, but his blood pressure was normal at that time. She stated there was nothing different she would have done for CR #1 with no symptoms and the nurses reported no symptoms and no distress. She said she did not receive a report that CR #1's oxygen saturation decreased during physical therapy. She said she was not an expert in that area (respiratory/pulmonary), so she did not know if going to the shower could have caused a change of condition so quickly. She said sometimes, therapy and showers could be a lot for a resident. She said she thought CR #1 was not ready to leave the hospital.
In a telephone interview with CNA B [DATE], at 1:30 p.m., she stated [DATE] was the first day she worked with CR #1. She said she met CR #1 when she made her first rounds on [DATE] (she could not recall wheat time it was). She said she was told by the previous shift that CR #1 required extensive assistance and he required oxygen. She said CR #1 did not speak English, but a family member who arrived after breakfast was able to translate. She said CR #1 said he was ready to take a shower, so she went to get a shower chair. She said CR #1 was on an oxygen concentrator in his room, so she got a portable tank and switched him from the concentrator to the tank. She said she told RN E she was going to get CR #1 for a shower because she needed to know what level of oxygen to put him on. She said the nurse said to put him on 5 L/min. She said as she pushed CR #1 down the hall in the shower chair, she had another Spanish staff member to verify that CR #1 could feel the oxygen from his nasal cannula. She said she left CR #1 in the shower room with his oxygen on after she took his gown and brief off. She said CNA A texted to let her know CR #1 was ready. She said CR #1 was fine at first, but as they went down the hall, he looked pale. She said she told RN E and she said to get CR #1 to his room, and she would go assess him. She said once she got to CR #1's room, he passed out. She said in the oxygen room, the full and empty tanks were separated. She said she regularly transported another alert and oriented resident on continuous oxygen (4 L/min) to and from the shower, and she never had problems with oxygen running out. She said when she picked CR #1 up from the shower, CNA A said CR #1 did not look the same. CNA B said CR #1 was not breathing heavily when she picked him up from the shower room, but when he was almost to his room, he started passing out. She said she was trained to change residents from the oxygen concentrator to the portable tanks and vice versa. She said she did not look at the portable oxygen tank when she picked CR #1 up because it should have been full when she put him on. She said CR #1 was in the shower for 20-25 minutes.
In a follow-up interview with the DON on [DATE], at 1:30 p.m., she stated she was present when CR #1 admitted to the facility. She said CR #1 was on 5 L/min of oxygen when he arrived, but she wanted to clarify with his doctor. She said she read the hospital records and CR #1 was on 4 - 5 L/min, so she wanted to talk to the doctor because they typically kept residents no higher than 4 L/min. She said the on-call doctor was contacted to verify CR #1's medications and they gave an order for 5 L/min. She said there was a typo in the electronic MAR for 2 - 4 L/min because the 4 was so close to the 5 on the keyboard. She said CR #1's family members told her at home, CR #1 he was on 8 L/min via nasal cannula. She said she told the family members that was not best route because the nasal cannula could only tolerate up to 6 L/min. She said she told them the facility had to get orders to increase the oxygen from what was on his hospital records. She said the CNAs were trained to switch residents from the concentrator to portable tanks as long as the nurse assessed the resident, and the nurse went in and made sure the resident was on the proper oxygen. She said it was ok for CNA B to switch CR #1 from the concentrator to the tank because the nurse saw the resident and he went to physical therapy as well. She stated she did not contact CR #1's physician about increasing his oxygen administration to 6-8 L/min during exertion because he tolerated 5 L/min well.
In a telephone interview with RN E on [DATE], at 12:09 p.m., she stated she only worked with CR #1 on Friday, [DATE]. She said when she arrived for her shift that morning (6:00 a.m. - 6:00 p.m.) she assessed CR #1 and found that his blood pressure was low. She said she could not recall what his blood pressure was, but she took it twice. She gave CR #1 fluids and when the ADON returned to check the blood pressure again at the NP's request, it was normal. She said later that morning, when physical therapy came, CR #1's oxygen was low, and he was weak. She said the PT told her CR #1 walked back and forth from the door to the bed and then his family member said when he was at home and doing therapy, they increased his oxygen to 7 and 8 L because his oxygen dropped during exertion. She said after lunch, she was on her way to another hall when a CNA called for her. She said a CNA brought CR #1 back from a shower and said he did not look ok. She said she looked at CR #1 and she had a flash-back of what the PT said about his oxygen in therapy. RN E said she looked at CR #1 and he looked ok, so she told the CNA to take CR #1 to his room. She said CR #1 looked weak but had oxygen on. RN E said the activity of the shower may have dropped CR #1's oxygen down. She said she told the CNA she was coming, but on her way back, about one minute later, the CNA came running down the hall and said CR #1 looked worse. She said she went to CR #1's room and he looked different and was unconscious. She said she started to do a sternal rub. She said she told the CNA to call a code blue and she started CPR. She said before they went to the shower, CR #1 was on a small oxygen tank. She said the oxygen was on, but she could not recall what level it was on. RN E initially said CR #1 was on 3 L/min of oxygen. RN E said she could not recall if the tank was full, but she knew it was working. RN E eventually said CR #1 was on 5 L/min of oxygen and when she looked at it, it was fine. She said CR #1 and CNA B were already in front of the shower room when she saw them. She said when CR #1 went unconscious, he was still in the shower chair. She said she checked for a pulse, but it was weak. She said they transferred CR #1 to the bed and started CPR. She said EMS came when he was already awake. She said CR #1 did not look pale to her when he came out of the shower. She said he looked weak, and she thought it was because he was used to increasing his oxygen during showers. She said she did not call CR #1's doctor to ask about increasing his oxygen after his oxygen saturation decreased during therapy, even though she was informed his family said to increase it. She said it was not even an hour after the PT told her that before the shower incident happened. She said she was already waiting on the doctor to respond to her about CR #1's critical CO2 lab result. She said after the PT told her about CR #1's desaturation during therapy, she received CR #1's critical lab and called for the doctor regarding the lab.
In an interview with the ADON on [DATE] at 11:30 a.m., she stated she was the one who entered CR #1's orders for oxygen into the MAR. She said after reading the hospital record, she understood CR #1 was tolerating 2-4 L of oxygen. She said she did not know the order was supposed to be 5 L. She said 5 L was the most a nasal cannula could tolerate. She said she had no interactions with CR #1's family until the code blue. She said she did not know where 6 - 8 L/min of oxygen came from. She said if CR #1's family said he was tolerating 6 - 8 L at home, his NP should have been contacted. She said that was the steps staff should have taken if the family said they wanted CR #1 on something different. She said the staff should have gotten guidance from the NP or doctor and educated CR #1's family that they got orders from medical providers.
In an interview with LVN D on [DATE], at 12:05 p.m., she stated she admitted CR #1 to the facility on [DATE]. She said CR #1 was on 5 L, so she left him on 5 L. She said CR #1's family said when he was at home, if he walked or moved around the house, they increased his oxygen 6 L. She said if she was working with him, she would have increased his oxygen in the shower if his family said that. She said she verified CR #1's medications with the NP by text. She said the NP instructed to continue with the admission orders. LVN D said she did not ask the NP about CR #1's oxygen administration and she did not enter his medications in the MAR. She said the nurse who admitted the resident was supposed to enter the medication, but she did not. She said she did not know why she did not enter the medications, she must have forgotten. She said once everything was explained to her, she knew it was her fault (the medication/oxygen error). She said there were no orders for oxygen from the hospital, but when the hospital gave report, it said 5 L.
In a telephone interview with CR #1's family member on [DATE] at 9:17 p.m., she stated CR #1 expired on [DATE] while at home on hospice care.
Record review of the facility's policy titled Significant Change of Condition, Response revised 12/2023 revealed, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure. 1. If, at ant time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Respiratory Care
(Tag F0695)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and interview, the facility failed to ensure that a resident who needed respiratory care was pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and interview, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 9 residents (CR #1) reviewed for respiratory care.
1.
The facility failed to increase CR #1's oxygen or consult/seek further guidance from CR #1's physician to increase his oxygen to 6-8 L/min during a shower on [DATE] after his family members informed staff his oxygen requirement increased during exerting activities, including showers. The facility failed to monitor CR #1's oxygen administration/O2 levels while in the shower and ensure CR #1's oxygen was working properly or immediately call for a nurse when CNA A and CNA B noted a change of condition (CR #1's skin color was pale). This resulted in CR #1's drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53%. CR #1 lost consciousness and required CPR and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). CR #1 expired on [DATE] on hospice at his home.
2.
The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy on [DATE].
3.
The facility failed to accurately document CR #1's order for 5 L/min of continuous oxygen on his MAR and instead listed 2-4 L/min of continuous oxygen.
An IJ was identified on [DATE] at 2:52 p.m The IJ template was provided to the facility on [DATE] at 2:52 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE].
These failures placed residents on continuous oxygen at risk of experiencing desaturation, unconsciousness, and death.
Findings include:
Record review of CR #1's face sheet, dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] from an acute care hospital. He was diagnosed with UTI (an illness in any part of the urinary tract), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), aphasia (a language disorder that affects a person's ability to communicate), acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when there is too much carbon dioxide in your body. It can happen all at once [acute] or come on over time [chronic]), and essential hypertension (a form of hypertension without an identifiable cause). CR #1 was discharged to an acute care hospital on [DATE].
Record review of CR #1's MDS dated [DATE] revealed he was admitted from an acute care hospital on [DATE].
Record review of CR #1's BIMS dated [DATE] at 2:55 p.m. revealed he had a score of 0 (severe cognitive impairment).
Record review of CR #1's Functional Abilities admission Assessment dated [DATE] revealed, MDS Reason for Evaluation: Admission/5-Day . Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury - Independent - Resident completed all the activities by themselves, with or without an assistive device, with no assistance from a helper . Prior Device Ise - Manual Wheelchair, [NAME] .
Record review of CR #1's care plan dated [DATE] revealed the following care area:
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ADL Self Care Performance Deficit. Goal included: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with modified independence. Interventions included: Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders; Toilet Use: requires assistance; Transfers (Chair /Bed to Chair Transfer, toilet transfers: Requires staff participation with transfers; Bed Mobility: Requires staff participation to reposition and turn in bed; Encourage to participate to the fullest extent possible with each interaction; Bathing (Shower/Bathe Self): Staff will provide the required assistance needed for bathing; Personal Hygiene/Oral care: Staff will provide the required assistance needed for personal hygiene/oral care; Dressing: Requires staff participation to dress; Eating: Staff will provide the required assistance needed for eating as needed.
Further review of CR #1's care plan revealed no focus/care area related to his respiratory condition or oxygen requirements/needs.
Record review of CR #1's preadmission hospital records dated [DATE] revealed he was admitted to a local acute care hospital on [DATE] for weakness and was diagnosed with complicated UTI (any UTI that is not considered simple, and defined by the presence of underlying conditions rather than the severity of the infection), acute on chronic respiratory failure with hypoxia, acute toxic metabolic encephalopathy (a condition that causes global cerebral dysfunction, resulting in altered consciousness, behavior changes, and seizures), acute diarrhea due to E.coli (diarrhea caused by bacteria), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary fibrosis (a condition in which the lungs become scarred over time), acute on chronic congestive heart failure (a type of heart failure that occurs when the heart has difficulty compensating for a loss of function that has developed over time) and history of CVA (a stroke; when blood flow to the brain is suddenly cut off) with global aphasia (a severe form of non-fluent aphasia caused by damage to the left side of the brain). The document read in part, . [CR #1] is a [AGE] year-old male with pulmonary fibrosis who was hospitalized for metabolic encephalopathy and atrial fibrillation with rapid ventricular response due to complicated UTI and infectious diarrhea. Patient improved with supportive measures including antibiotics and rate control. Patient was discharged in stable cardiology and pulmonology for continued evaluation and management as outpatient . Review of Systems . Respiratory: Negative for cough, shortness of breath, and wheezing . Respiratory/Pulmonary Interventions Documentation: . Respiratory Quality/Sounds: Dyspnea (shortness of breath) on exertion, dyspnea laying flat, dyspneic (having difficulty breathing or being unable to breathe without effort), tachypneic (fast breathing) . Respiratory/Pulmonary Interventions: O2 Delivery Method: Nasal cannula; O2 flow rate (L/min): 5 L/min . [DATE] . History of Present Illness . He was on baseline O2 of 4-5 L/min . Patient was admitted for further evaluation . He developed episode of a-fib and SOB/cough overnight, given breathing treatments and IV metoprolol (a medication used to treat high blood pressure, chest pain, and heart failure) . Currently he is resting in bed, no acute distress. On 6L/min via nasal cannula . Pulmonary and Critical Care Consult Note, [DATE]. Assessment: Chronic hypoxic respiratory failure with home oxygen dependence between 4 to 6 L/min at baseline, 8L with exertion . Pulmonary Progress Note: [DATE] . Patient states his breathing feels comfortable at his baseline oxygen requirement of 5L/min . He has been saturating at 100% .
Record review of CR #1's Initial admission Record dated [DATE] revealed LVN C wrote . Most Recent O2 saturation: 98% ([DATE] at 5:15 p.m.) Method: oxygen via nasal [cannula] . General Skin Condition: Normal - Yes, Pale/Ashen - No, Flushed - No, Cyanotic (bluish or purple discoloration) - No . Pulmonary System. Diagnosis: Does the Resident have a Pulmonary Diagnosis - No . Pulmonary System. Oxygen. Oxygen Use - No .
Record review of CR #1's physician's orders for [DATE] revealed:
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Check and record O2 Saturation every shift. Order Date: [DATE]. Start Date: [DATE].
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O2 at 2-4 L/Min Continuous per nasal cannula every shift. Order Date: [DATE]. Start Date: [DATE]
Record review of CR #1's MAR for [DATE] (there was no MAR for [DATE]) revealed:
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Check and record O2 Saturation every shift. There were no entries for this order. CR #1 was hospitalized .
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O2 at 2-4 L/Min Continuous per nasal cannula every shift. There were no entries for this order. CR #1 was hospitalized .
Record review of CR #1's progress notes for [DATE] revealed:
On [DATE], LVN D wrote, At 5:15 p.m., patient arrived as a new admit to the facility via wheelchair with belongings . O2: 98% 5L of O2. NP notified of admit and verified orders and lab orders for CBC and BMP.
Record review of CR #1's progress notes for [DATE] revealed:
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On [DATE] at 1:57 p.m., LVN E wrote, COC for CO2 of 45 (normal range 21.0 - 31.0). Resident has a critical lab of CO2 45, NP informed and awaiting new orders.
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On [DATE] at 6:08 p.m., LVN E wrote, Resident had just finished taking a shower when the CNA [CNA B] brought out the resident from the bathroom looking weak but breathing. This nurse told the CNA to take resident back to his room. Later this nurse was called by CNA that resident is not looking good. This nurse did a sternal rub (a painful stimulus used to assess a patient's neurological status and responsiveness) on patient and observed that the patient was still unresponsive and had a weak pulse. This nurse told CNA to call code blue. Patient was then transferred from shower chair to bed. Chest compressions began immediately. Staff members rushed in with crash cart at bedside and placed back board underneath. Another staff called 911, while using the non-rebreather to deliver oxygen. Another staff focused putting in a peripheral IV line for fluid. Blood sugar was checked. O2 sat 58% according to pulse oximetry. Resident started moaning and moving his lower extremities just before 911 ambulance arrived to take over. Resident was later taken to the hospital.
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On [DATE] at 11:28 a.m., the DON wrote, IDT met to discuss [CR #1]. During review, it was noted that resident's order for O2 2-4LPM was incorrectly typed and should have been 2-5LPM as resident order verified for 2-5LPM upon resident admission with NP. Resident admitted 10/31 at approximately 5:15 from hospital on 5L of O2 [saturating] at 98% with diagnosis of Pulmonary Fibrosis, UTI, Aphasia . On 11/1, resident participated in physical therapy, speech therapy, and occupational therapy. During therapy session, resident was on 5L of oxygen and oxygen was monitored throughout session and remained between 86% and 95% on 5LPM per NC. Later in the day, around 3:00 p.m. resident was taken for a shower. Resident was taken to the shower with oxygen and remained on oxygen therapy throughout the duration of the shower. Shower CNA [A] stated that during his shower, he had his oxygen on, and was alert throughout the course of his shower. Towards the end, resident began to appear weak. CNA [A] called to CNA [B] to come assist. When CNA [B] was transferring the resident back down to his room, resident began to slump in his chair. CNA [F] assisted with getting resident to the room and called to the nurse for assistance with family at bedside. When the nurse arrived at the room, resident was unresponsive to stimuli, RN [E] called code blue and CPR was initiated. Oxygen was changed from NC to NRB and [O2] sat noted to be at 58%. 911 was called by other staff. When EMS arrived, resident had pulse and was responsive.
Record review of CR #1's PT Evaluation and Plan of Treatment completed by the PT and dated [DATE] revealed, . Cardiopulmonary Assessment - At rest: . Oxygen saturation: 98 (on 5 L). Activity: Patient's rated/reported level of exertion = Patient is unable to communicate exertion felt during activity. Oxygen saturation with activity: 86 [%](on 5L) .
Record review of CR #1's EMS records dated [DATE] revealed, . Call Received: 3:51 p.m. On Scene 3:59 p.m.Depart Scene: 4:41 p.m. Chief Complaint: Patient is a [AGE] year-old male with complaints of unconscious and respiratory distress. Patient is unconscious, cannot sit up and cannot ambulate with assistance . History: The issue with cardiac arrest began more than 5 minutes ago . Treatment (Plan): Stopped CPR and found spontaneous pulses and irregular respirations . SPO2 (4:06 p.m.: 89%), (4:16 p.m.: 96%) .
Record review of CR #1's hospital records dated [DATE] revealed he was transferred from the facility to the ER then ICU of a local acute care hospital on [DATE]. He was intubated and was diagnosed with cardiac arrest (when the heart suddenly stops beating). The document read in part, . Brought in by EMS [from facility]. CPR in progress upon EMS arrival, staff was doing compressions. Patient was moving around and had a pulse but decreased respiratory effort . Physical Exam ([DATE]) General: He is in acute distress. Appearance: He is ill-appearing . Pulmonary: Patient is having assisted ventilation . Neurological: Unresponsive .
Observation and interview with CR #1 on [DATE], at 2:45 p.m. revealed he was in the ICU at a local acute care hospital. CR #1 was intubated and opened his eyes to verbal stimuli. CR #1 did not attempt to communicate or make any gestures unless a family member spoke to him. There were multiple family members present at that time. Two family members stated they were present at the facility when CR #1 was admitted to the facility on [DATE]. Both family members stated they informed staff at the facility they would have to increase CR #1's oxygen to 6 - 8 L/min while he was in the shower as they had to do at home. The family members stated the DON told them staff had equipment in the shower to monitor CR #1's oxygen. One family member said CR #1 was able to tell them he remembered being at the facility, but he could not recall what happened in the shower. Another family member who only spoke Spanish (translated by an English speaking family member) stated CR #1 complained about the oxygen in that place and he told her through nodding and gestures that he did not have what he needed. CR #1 did not answer questions at that time.
In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted on [DATE] and was sent out on [DATE] when he coded in respiratory/cardiac arrest around 4:00 p.m. She said CR #1's oxygen saturation dropped significantly, and he was non-responsive. She said CR #1 received therapy on [DATE] and then he was taken to the shower. The DON said while CR #1 was going back to his room, he became week and then became unresponsive. She said CR #1 was on continuous oxygen and had it on the whole time he was in the shower. She said she investigated the incident after CR #1 was discharged to the hospital on [DATE]. She said CR #1 never went without his oxygen while he was at the facility. She said he transferred from the hospital on [DATE] on 5 L/min of oxygen. She said she verified with the nurses, CNA's and therapist that CR #1 was always on 5 L/min. The DON said she would have gotten a physician's order for more oxygen, but CR #1 was tolerating 5 L/min during exertion (she did not specify which exerting activities). She stated throughout CR #1's time in therapy, he remained between 86% and 95% oxygen saturation (according to the American Lung Association, dated [DATE], a person with pulmonary fibrosis should maintain an oxygen saturation level above 90% throughout the day and night). She stated that level was good given his diagnosis of pulmonary fibrosis. She stated when CR #1 went into distress, his oxygen saturation level was 58% on a non-rebreather (a medical device that delivers a high concentration of oxygen). She stated she spoke with CR #1's family and she told them all of CR #1's orders from the hospital indicated he should have been on 2 - 4 L/min of oxygen, but up to 5 L/min if in distress. She stated CR #1 could not walk, he was aphasic, but was alert and aware. She said CR #1 remained alert in the shower until staff transferred him back to his room in a wheelchair.
In an interview with the ADON on [DATE], at 10:55 a.m., she stated she had never seen CR #1 until [DATE], when the code blue (used to indicate that a patient requires resuscitation or is in need of immediate medical attention) was called. She said she got involved because she heard the code blue. She said when she went to CR #1's room, she assisted other staff with moving him from the shower chair to his bed and then she provided chest compressions during CPR. She said they initiated CPR in CR #1's bed with a back board. She said CR #1 had a weak pulse and responded well to chest compressions. She said CR #1 began to make noises and then she assessed his pupils. She said CR #1 blinked hard and then started moving his legs before EMS arrived. She said CR #1 had a nasal cannula and was on a portable oxygen tank until staff traded out for the ambu bag (a manual resuscitator or self-inflating bag) to administer breaths. She stated the portable oxygen tanks had a gauge on it which indicated how much oxygen it contained. She said all the portable oxygen tanks went up to 5 L/min. She stated she never sat and watched a portable oxygen tank as it administered oxygen, so she could not say how long a small portable oxygen tank (like the one used in the shower with CR #1) would last on 5 L/min. She stated the tank did not make a sound if it was going empty. She said staff charged (filled the tanks with oxygen) the portable tanks regularly and they would not have put CR #1 on a used (one that was not full) tank. She said normal protocol would be for the CNA or nurse to go get a portable tank. She said a CNA would tell a nurse when a resident was about to take a shower and the CNA would ask the nurse to swap the resident from the oxygen concentrator (the resident would have been on an oxygen concentrator inside their room) to a portable tank. She said the nurse would check to make sure the portable tank was full.
In an interview with CNA A on [DATE], at 11:20 a.m., she stated she worked at the facility as a shower aide. She stated she only interacted with CR #1 one time ([DATE]). She said she had never seen CR #1 before he was brought to her in the shower room on [DATE]. She said the assigned CNA brought residents to the shower room and went back to pick them up after their shower to go back to their rooms. She said when CNA B brought CR #1 to the shower room, he was on oxygen via nasal cannula and in a shower chair. She said she tried to communicate with CR #1, but he did not really talk. She said CR #1 may have said some words, but they were in Spanish. She said CR #1 was not breathing heavily or abnormally. She said CR #1 seemed to be weak. She said during the shower, she did all the work, other than raising his arm when she asked him to. She said she was in the shower alone with CR #1 until CNA B came back to get him. She said she only looked at CR #1's portable oxygen tank when he initially arrived at the shower room, and he was on 5 L/min. She said she had to carry the portable tank and she saw 5 L/min and it was full. She said she carried the tank over to where she dried and dressed CR #1. She said the only time she noticed a change in CR #1 was when CNA B looked inside the door after he was dressed. She said she told CNA B that she did not think CR #1 looked too good. She said CR #1's color changed, and he looked pale to her. She said CR #1's breathing was the same (normal) and he was sitting straight up in his chair, not slumped over. She said all CNAs were trained to recognize changes of condition, including respiratory distress. She said the only way she could have known if CR #1's oxygen was on was if she checked the nasal cannula to see if air was coming out because the oxygen did not make sound. She said she did not check CR #1's oxygen after the shower started.
In a telephone interview with CR #1's family member on [DATE], at 11:32 a.m., she stated CR #1 was currently in the ICU and the family was asked to place him on hospice (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). She said when she spoke to the facility's DON after CR #1 was transferred to the hospital, she said maybe the hospital discharged CR #1 before he was ready. She stated CR #1's oxygen never decreased (desaturated) as low as it did on [DATE]. She said CR #1 was almost unresponsive when he returned to his room, and she wanted to know how he got to that point because it never happened before. She said CR #1's oxygen levels were never an issue at the hospital prior to his admission to the facility. She stated the hospital doctor told her that CR #1's oxygen level went too low, and his body shut down and it looked like cardiac arrest. She said CR #1's baseline oxygen requirement was 4 L/min at rest and 6 - 8 L/min with exertion. She said CR #1 had therapy on Friday, [DATE] and the therapist told her they had to increase his oxygen while in therapy. She said she informed the admitting nurse on Thursday, [DATE], and the therapist on Friday, [DATE] they would have to increase CR #1's oxygen to 6 - 8 L/min on exertion, including walking and showers. She said the DON told her CR #1 was on 4 L/min when they took him to the shower. She said another family member was in CR #1's room on [DATE] when staff took him to the shower. She said the other family member said they were in the shower for 30 minutes and when CR #1 returned to his room, he was slumped over and unresponsive.
In an interview with the PT on [DATE], at 12:15 p.m., she stated she evaluated CR #1 on [DATE] and she did not know he was transferred to the hospital until [DATE]. She said she went to CR #1's room on [DATE] to evaluate him for physical therapy and occupational therapy right after breakfast. She said when she arrived at his room, he was in bed with oxygen on via nasal cannula. She stated CR #1 was aphasic and was not able to verbalize, but he used gestures and pointed to things to communicate. She stated he did speak in a mix of broken Spanish and English and he was able to follow directions. She said she worked with CR #1 on walking from the bed to the bathroom door, about 10-12 feet. She said CR #1 did alright, but she noticed he was exhibiting signs of SOB, so she checked his oxygen. She said she could not recall what CR #1's oxygen saturation was. She said she instructed CR #1 to breath properly and deeply. She said CR #1 followed instructions and his oxygen saturation went up without increasing his oxygen. She said she assisted CR #1 back to bed and told him he would start therapy. She said she told his nurse (RN E) CR #1's oxygen saturation decreased when she walked him, so the nurse was aware. She said she wanted to get information about CR #1's baseline, so she called his family member. She said CR #1 was already breathing heavily when he was lying down before therapy because she could see his chest and stomach rise and fall. She said CR #1 was on 5 L/min of oxygen according to his physician's order. She said when she called CR #1's family member after the evaluation, the family member mentioned that at home, he was on 5 L/min. She said she did not increase CR #1's oxygen during the evaluation because she did not have the authority to do that, and he was fine after doing proper breathing exercises.
In a telephone interview with CR #1's NP on [DATE], at 12:57 p.m., she stated CR #1 admitted on [DATE] after she had already completed rounds at the facility, so she never met him. She stated she did not recall speaking to anybody regarding his medications, so staff must have verified his physician's orders with the on-call physician. She stated it was hard to say if 1 L/min of oxygen would have made a difference for CR #1. She said with his history of pulmonary fibrosis, usually a higher oxygen level did not guarantee better perfusion of lungs. She said she did receive a report that CR #1's blood pressure was slightly low (she could not recall when she received this report), so she called the DON to go assess and recheck, but his blood pressure was normal at that time. She stated there was nothing different she would have done for CR #1 with no symptoms and the nurses reported no symptoms and no distress. She said she did not receive a report that CR #1's oxygen saturation decreased during physical therapy. She said she was not an expert in that area (respiratory/pulmonary), so she did not know if going to the shower could have caused a change of condition so quickly. She said sometimes, therapy and showers could be a lot for a resident. She said she thought CR #1 was not ready to leave the hospital.
In a telephone interview with CNA B [DATE], at 1:30 p.m., she stated [DATE] was the first day she worked with CR #1. She said she met CR #1 when she made her first rounds on [DATE] (she could not recall wheat time it was). She said she was told by the previous shift that CR #1 required extensive assistance and he required oxygen. She said CR #1 did not speak English, but a family member who arrived after breakfast was able to translate. She said CR #1 said he was ready to take a shower, so she went to get a shower chair. She said CR #1 was on an oxygen concentrator in his room, so she got a portable tank and switched him from the concentrator to the tank. She said she told RN E she was going to get CR #1 for a shower because she needed to know what level of oxygen to put him on. She said the nurse said to put him on 5 L/min. She said as she pushed CR #1 down the hall in the shower chair, she had another Spanish staff member to verify that CR #1 could feel the oxygen from his nasal cannula. She said she left CR #1 in the shower room with his oxygen on after she took his gown and brief off. She said CNA A texted to let her know CR #1 was ready. She said CR #1 was fine at first, but as they went down the hall, he looked pale. She said she told RN E and she said to get CR #1 to his room, and she would go assess him. She said once she got to CR #1's room, he passed out. She said in the oxygen room, the full and empty tanks were separated. She said she regularly transported another alert and oriented resident on continuous oxygen (4 L/min) to and from the shower, and she never had problems with oxygen running out. She said when she picked CR #1 up from the shower, CNA A said CR #1 did not look the same. CNA B said CR #1 was not breathing heavily when she picked him up from the shower room, but when he was almost to his room, he started passing out. She said she was trained to change residents from the oxygen concentrator to the portable tanks and vice versa. She said she did not look at the portable oxygen tank when she picked CR #1 up because it should have been full when she put him on. She said CR #1 was in the shower for 20-25 minutes.
In a follow-up interview with the DON on [DATE], at 1:30 p.m., she stated she was present when CR #1 admitted to the facility. She said CR #1 was on 5 L/min of oxygen when he arrived, but she wanted to clarify with his doctor. She said she read the hospital records and CR #1 was on 4 - 5 L/min, so she wanted to talk to the doctor because they typically kept residents no higher than 4 L/min. She said the on-call doctor was contacted to verify CR #1's medications and they gave an order for 5 L/min. She said there was a typo in the electronic MAR for 2 - 4 L/min because the 4 was so close to the 5 on the keyboard. She said CR #1's family members told her at home, CR #1 he was on 8 L/min via nasal cannula. She said she told the family members that was not best route because the nasal cannula could only tolerate up to 6 L/min. She said she told them the facility had to get orders to increase the oxygen from what was on his hospital records. She said the CNAs were trained to switch residents from the concentrator to portable tanks as long as the nurse assessed the resident, and the nurse went in and made sure the resident was on the proper oxygen. She said it was ok for CNA B to switch CR #1 from the concentrator to the tank because the nurse saw the resident and he went to physical therapy as well. She stated she did not contact CR #1's physician about increasing his oxygen administration to 6-8 L/min during exertion because he tolerated 5 L/min well.
In an interview with multiple hospital nurse managers and one hospital physician on [DATE], at 10:00 a.m., one nurse stated CR #1 had six hospital stays and three ER visits in 2024. The nurse stated CR #1 arrived at the hospital on [DATE] in cardiac arrest but it was hard to say whether his blood pressure dropped first and caused his oxygen to drop, or if his respiratory distress caused his blood pressure to drop. Another nurse stated CR #1's cardiac arrest was due to his respiratory desaturation. The physician stated CR #1's condition deteriorated over time, and he had become more and more short of breath. He said CR #1's chronic lung disease and the probability that he did not have enough air could have led to a quick desaturation. He stated 8 L of oxygen may not have made a difference, but in the shower, CR #1 would have required a little bit more oxygen. He said since it was an acute event, he did not know if 8 L of oxygen would have made a difference. He said CR #1 was diagnosed with aspiration pneumonia (a type of lung infection due to a relatively large amount of material from the stomach or mouth entering the lungs) and his prognosis was poor.
In a telephone interview with RN E on [DATE], at 12:09 p.m., she stated she only worked with CR #1 on Friday, [DATE]. She said when she arrived for her shift that morning (6:00 a.m. - 6:00 p.m.) she assessed CR #1 and found that his blood pressure was low. She said she could not recall what his blood pressure was, but she took it twice. She gave CR #1 fluids and when the ADON returned to check the blood pressure again at the NP's request, it was normal. She said later that morning, when physical therapy came, CR #1's oxygen was low, and he was weak. She said the PT told her CR #1 walked back and forth from the door to the bed and then his family member said when he was at home and doing therapy, they increased his oxygen to 7 and 8 L because his oxygen dropped during exertion. She said after lunch, she was on her way to another hall when a CNA called for her. She said a CNA brought CR #1 back from a shower and said he did not look ok. She said she looked at CR #1 and she had a flash-back of what the PT said about his oxygen in therapy. RN E said she looked at CR #1 and he looked ok, so she told the CNA to take CR #1 to his room. She said CR #1 looked weak but had oxygen on. RN E said the activity of the shower may have dropped CR #1's oxygen down. She said she told the CNA she was coming, but on her way back, about one minute later, the CNA came running down the hall and said CR #1 looked worse. She said she went to CR #1's room and he looked different and was unconscious. She said she started to do a sternal rub. She said she told the CNA to call a code blue and she started CPR. She said before they went to the shower, CR #1 was on a small oxygen tank. She said the oxygen was on, but she c[TRUNCATED]
Sept 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse.
The facility failed to prevent Resident #1 from being physically abused by LVN B on 12/05/23.
The noncompliance was identified as past noncompliance (PNC) IJ. The noncompliance began on 12/05/23 and ended on 12/12/23. The facility corrected the noncompliance before the survey began.
This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress.
Findings included:
Record review of Resident #1's face sheet dated 09/25/24 revealed an [AGE] year-old female admitted to the facility initially on 11/09/21 and readmitted [DATE]. Resident #1 had diagnoses which included Major depressive disorder (mental health condition that cause loss of interest in activities that once brought joy), dementia (impair ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness).
Record review of Resident #1's quarterly MDS assessment, dated 09/09/2024, revealed a BIMS score of 02 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #2's MDS revealed the resident needed extensive assistance with ADL care.
Record review of Resident #1's undated care plan initiated 11/09/21 revealed: Resident #1 had impaired cognitive function or impaired thought processes related to Dx of Dementia. An intervention included: Communication: Identify yourself at each interaction, face when speaking and make eye contact, use simple, directive sentences, provide with necessary cues- stop and return if agitated.
Observation and interview on 09/24/24 at 11:20 a.m., Resident #1 was in bed, and she was dressed in her street clothes. Resident #1 was not able to say if the staff was abusive to her. Resident #1 was a poor historian.
During an interview on 09/24/24 at 1:40 a.m., ADON A said there was an issue on 12/04/23 with LVN B when Resident #1 bumped into LVN B while she stood by the medication cart in front of the nursing station. ADON A said LVN B turned around and pushed Resident #1's wheelchair away and leaned forward in front of Resident #1 while she talked to Resident #1 aggressively, but there was no audio. ADON A said LVN B slapped Resident #1's hand away when Resident #1 raised her hand. ADON A said there was no reason for LVN B to physically abuse Resident #1.
During an interview on 09/24/24 between 10:47 a.m. and 5:54 p.m., (2 LVN, 1 CNA, 1 MA, 1 shower teach) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received.
During an interview on 09/25/24 at 11:35 a.m., the DON said while she was making rounds on 12/05/23, a resident told her she heard loud noise last night (12/05/23). The DON said she reviewed the facility camera and saw LVN B standing in front of the medication cart by the nursing station when Resident#1 bumped into LVNA B. The DON said LVN B shoved Resident #1's wheelchair back forcefully, leaned forward to Resident #1, and pointed to Resident#1's face, but she could not hear what she said because the camera had no audio. The DON said LVN B's demeanor was intimidating, and it made her the DON sick. The DON said the video of the incident was not available to be reviewed when surveyors entered. The DON said she immediately reported it to HHSC. The DON said she called LVN B at home and told LVN B she could not return to the facility because of the incident, and LVN B was terminated after the facility investigation, which indicated LVN B abused Resident #1.
During an interview on 09/25/24 at 11:43 a.m., the DON said they had QAPI about the incident, in-service with the staff on abuse/neglect, they did safe survey with residents, and the DON would train new staff upon hire on abuse/neglect.
During an interview on 09/24/24 between 12:7 a.m. and 3:25 p.m., (3 LVN, and 1 CNA) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received.
Record review of the provider investigation report dated 12/05/23 revealed LVN B written statement reflected, I would never treat my patients in such a way. I was doing my job at the nurse's cart when the resident approached me demanding coffee. I told her that the kitchen was closed for the day, and she continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her chair away to prevent injury to myself. I then attempted to redirect the resident by getting eye level with her and gestured to her, the kitchen is closed. She then attempted to hit me, so I attempted to block her from injuring me . the facility investigation reflected the incident happened on 12/5/23, and abuse was substantiated . Director of Nursing viewed security footage from around 7pm the night prior and noted an interaction between Resident #1 and LVN B. Footage revealed that Resident #1 was in her wheelchair rolling
slowly towards the dining room. She stopped shortly next to LVN B at her nursing cart, at the nurse's station. Resident#1 then proceeded to propel herself slowly bumping LVN B's foot. In response, LVN B forcefully pushed Resident #1's wheelchair backwards and proceeded to point her finger at Resident #1. Verbal interaction took place between Resident #1 and LVN B. Resident #1 appeared to start yelling at the nurse and in return LVN B
leaned forward into Resident#1's face. Resident #1 swung her hand toward the nurse and LVN B batted Resident #1 hand away. After review of footage, LVN B was suspended immediately pending investigation. The interventions during investigation were physician notified, responsible party notified, sheriff's department notified, safe surveys, abuse and neglect in services LVN suspended and terminated .
Record review of the facility report of progress to the CQI Committee dated 12/12/23 reflected in part . PROBLEM
Nurse became physically aggressive and intimidating to resident.
CAUSAL FACTORS
nurse startled by being bumped into by resident wheelchair.
Nurse reaction to dementia resident behavior
INTERVENTION(S)
a. On-going education for abuse and
neglect, b. Re-educate facility staff on handing.
residents with behaviors and dementia, c. DON/Designee to review all new hire background checks, d. Medical Director Notified, e. Safe Surveys
f. RP notified, g. Police notified, h. Discuss on-going education and background checks in monthly QAPI.
i. ensure Relias trainings are completed before new hires start training and are completely annually by all staff.
Record review of LVN B employee file reflected the following: DOH: 03/27/2020. Criminal background checks completed 03/26/2020. DADS check completed 03/27/2020. EMR: 11/07/2023.
Record review of the facility policy on abuse dated 11/2017, revision 12/2023 reflected in part .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations . Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .
Nov 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #60) reviewed for ADL care.
1.
The facility failed to ensure Resident #60 was provided incontinent care in a timely manner .
2.
The facility failed to ensure Resident #60 was provided grooming (dry skin) causing her skin to be dry and flaky.
These failures could place residents at risk for discomfort, and dignity issues.
Findings included:
1. Record review of Resident #60's face sheet, dated 11/10/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included Morbid (severe) obesity (weight is more than 80 to 100 pounds above ideal body weight), hypertension (a condition in which the blood vessels have persistently raised pressure), and diaper dermatitis (a form of irritated skin).
Record review of Resident #60's quarterly MDS assessment, dated 09/22/2023, reflected a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident # 60's functional status reflected she required extensive assistance with one staff for ADL care. Resident #60 was incontinent of bladder and bowel.
Record review of Resident #60's care plan, revision date 10/19/23, reflected: Resident #60 had bladder/bowel incontinence related to impaired mobility, loss of peritoneal tone, and overactive bladder which placed her at risk for skin breakdown and infection. Interventions: Incontinent: check as required for incontinence. Wash, rinse, and dry perineum. Monitor for signs and symptoms of UTI , pain burning, foul and smelling urine .
During an interview on 11/07/23 at 10:05 a.m., Resident # 60 said she wanted to be changed when CNA M came in this morning and changed her roommate, and she told her she had to wait. Resident # 60 said she was changed by the night shift aide around 4:30 a.m .
During an observation on 11/07/23 at 10:32 a.m., Resident # 60's incontinent brief change provided by CNA M reflected brief was saturated from front to back. The inside of the incontinent brief was brown, and the wet indicator was faded entirely.
During an interview on 11/07/ 23 at 12:14 p.m., CNA M said she was Resident #60's aide and came to work at 6:00 a.m. CNA M said she had not provided incontinent care for Resident #60 since she arrived this morning because the night shift changed Resident #60, and she was not getting her out of bed this morning. CNA M said the aides usually changed residents who were left in bed after breakfast. She stated she had not gotten to Resident #60 to change her incontinent brief until 10:30 a.m. because she was busy. CNA M said Resident # 60's incontinent brief was wet with urine from front to back, and the wet indicator lines faded out. CNA M said if she did not change Resident # 60 timely, she could develop rashes and wounds. CNA M said she was supposed to make rounds every two hours for incontinent care and change the resident if the resident was wet. CNA M said the charge nurse monitored the aides by marking random rounds, and the ADON monitored the charge nurses. She said she had an in-service on rounding and incontinent care.
During an interview on 11/08/23 at 1:39 p.m., the DON said CNA M should make rounds every two hours, check on residents, and provide incontinent care for residents who needed care. The DON said it was not the facility protocol to change only the residents who were getting up in the morning. CNA M had to change the residents she would be getting up first and then use her discretion on whom CNA M would change next. The DON said Resident #60 could have skin irritation if left in a wet brief. The DON said the charge nurse monitored the aides to make sure they were providing care to the residents. The DON said the ADON monitored the nurses, and the ADON should have the answer to how she monitored the nurses for care.
During an interview on 11/09/23 at 1:27 p.m., ADON said CNA M should make rounds every two hours and as needed to provide incontinent care for Resident #60. ADON said it was unacceptable not to change Resident # 60 because she was not being assisted out of bed that morning. ADON said Resident #60 could sustain skin breakdown, skin irritation, skin infection, and UTI. ADON said when the wet indicator faded out, and the brief was saturated, it meant Resident #60 had not been changed for some time. ADON said the charge nurse monitored the aides by making random rounds, and ADON LT said she monitored the charge nurses by making random rounds and asked the residents if they were changed .
2. During an observation on 11/07/23 at 10:45 a.m., revealed Resident #60's skin from her knees down to her feet were dry and flaky, and there was a substantial amount of flaked dry skin on Resident #60's mattress.
During an interview on 11/07/23 at 11:00 a.m., CNA P said she saw Resident #60's mattress had a lot of dry skin. CNA P said Resident #60's aide should have applied lotion on Resident #60's skin on shower days and any time Resident # 60's skin was dry. She stated that it was to prevent it from flaking off, such as the dry flaked skin on Resident #60's mattress. CNA P said Resident #60's skin could break down if dry skin was not prevented or treated .
During an interview on 11/07/23 at 11:04 a.m., Resident #60 said the nurses should apply lotion on her skin after showering on Tuesday, Thursday, and Saturday. She stated lotion should be applied when her skin was dry on the days she did not shower, but sometimes the nurse did not apply any cream on her .
During an interview on 11/07/23 at 12:16 p.m., CNA M said Resident #60's skin was dry and flakey from her knees down to her feet, and there was a lot of flaked skin on Resident #60's mattress. CNA M said Resident #60 was showered on Tuesday, Thursday, and Saturday, and the aide who showered Resident # 60 should have applied lotion on her . CNA M said if Resident #60's skin continued to fall off, she could have a skin tear or a wound. CNA M said the nurse made random rounds to monitor the aides. CNA M said she had not applied any lotion on Resident #60's legs before now , but she would apply cream later. CNA M said she had skills checked off on shower.
During an interview on 11/08/23 at 2:49 p.m., the DON said she would talk to Resident #60's provider about applying lotion on Resident #60's skin. The DON said Resident #60 could have skin break down if her skin continued to flake off.
During an interview on 11/09/23 at 1:51 p.m., ADON said Resident #60 should get a shower at least three times a week, and the aide who showered Resident #60 should apply lotion on her skin on her shower days and as needed. ADON said the aides should often lotion Resident #60's legs to prevent dry skin flakes. ADON said Resident #60's skin could develop wound and infection if the skin opened.
Record review of the facility policy on bath, and shower, revised 05/2007, read in part . this facility policy to promote cleanliness, stimulate circulation and assist in relaxation . procedures: dependent residents: #6. Apply lotion
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder recei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #60) reviewed for incontinent care.
- The facility failed to ensure CNA M completely cleaned Resident #1 during incontinent care.
This failure could place residents at risk for pain, infection, injury, and hospitalization.
Findings included:
Record review of Resident #60's face sheet, dated 11/10/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included Morbid (severe)obesity (weight is more than 80 to 100 pounds above ideal body weight), hypertension (a condition in which the blood vessels have persistently raised pressure), and diaper dermatitis (a form of irritated skin ).
Record review of Resident #60's quarterly MDS assessment, dated 09/22/2023, reflected a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident #60's functional status reflected she required extensive assistance with one staff for ADL care. Resident #60 was incontinent of bladder and bowel.
Record review of Resident #60's care plan, revision date 10/19/23, reflected: Resident #60 had bladder/bowel incontinence related to impaired mobility, loss of peritoneal tone, and overactive bladder which placed her at risk for skin breakdown and infection. Interventions: Incontinent: check as required for incontinence. Wash, rinse, and dry perineum. Monitor for signs and symptoms of UTI, pain burning, foul and smelling urine.
During an observation of incontinent care provided by CNA M for Resident #60 on 11/07/07/23 at 10:32 a.m., revealed, CNA M did not wash or sanitize her hands before she donned double gloves and placed the clean incontinent brief and a packet of wipes on Resident 60's bed. CNA M assisted Resident #60 to her right side, facing the window. CNA M removed the dirty incontinent brief, which was saturated with urine from front to back. CNA M took wipes from the wipe packet with the same dirty gloves and used the same gloves from beginning to end. She did not separate Resident #60's labia to clean it. CNA M did not clean under Resident #60's abdominal folds close to the peri area. CNA M also did not clean Resident #60's right buttocks, and she wiped the resident three times with the same wipe before she took another clean wipe.
During an interview on 11/07/23 at 12:18 p.m., CNA M said she did not separate or clean Resident #60's labia and did not clean under her abdominal folds when she provided incontinent care. CNA M said if she did not clean the labia properly, Resident #60 could get an infection and rashes. CNA M said if she did not clean Resident#60's abdominal folds , her skin could break down. CNA M said she should have wiped the resident once with one wipe instead of multiple times (three or four).
During an interview on 11/08/23 at 2:20 p.m., the DON said her expectation for CNA M was to knock on the door, introduce herself, and explain to Resident #60 she would provide incontinent care. The DON said CNA M should either sanitize her hands or wash her hands, disinfect the bedside, and set up her supplies for incontinent care. The DON said CNA M should have separated Resident #60's labia and abdominal folds and cleaned the areas to avoid build-up, skin breakdown, and infection.
During an interview on 11/09/23 at 1:31 p.m., ADON said CNA M should separate Resident # 60's labia and clean each side with one wipe to prevent Resident #60 from getting infection and skin breakdown. ADON said CNA M should have used a wipe one time. ADON said CNA M should have lifted the abdominal folds by the peri area, cleaned it, got in-between creeks and crannies, and cleaned them.
Record review of the undated facility policy on perineal care read in part . protocol . clean perineum, eliminate odor, prevent infection and irritation .
Record review of the facility perineal requirements November 2023 read in part . procedure : female: separate labia wash urethral area first . rationale: washes pathogens from the meatus . perform hand hygiene . apply clean gloves .
Record review of CNA M revealed she signed perineal care training dated November 2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitche...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that:
-The facility failed to dispose of expired food items and keep Scoops stored outside of food bins.
These failures could place residents at risk of food borne illness and diseases.
Findings include:
Observation of the facility's kitchen and interview on 11/07/23 between 8:30 am and 8:40 am with the Food Service Manager revealed the following:
Sliced American Cheese in a plastic container dated 10/27/23 stored in the refrigerator.
Sliced Swiss Cheese in a plastic container dated 10/03/23 stored in the refrigerator.
Cheese Parmigiana in a plastic container dated 9/07/23 stored in the refrigerator.
Scoops for bulk food were left in the sugar and flour bins stored in the storeroom.
Interview with the Dietary Food Service Manager on 11/07/23 at 8:35 AM, stated that the plastic containers with cheese should have been used or discarded prior to the used by date. The Scoops for bulk food should be stored in the storeroom, it was not to be stored in the food bin.
Interview with the Food Service Manager on 11/07/23 at 9:00 AM, she stated she was responsible for training staff on labeling and storage requirements, ensuring dietary requirements were met. She further stated she would in- service the dietary staff on refrigerated storage, practices to maintain safe refrigerated storage, labeling, dating, and monitoring refrigerated food.
Record review of facility's Policy Food Safety Requirements dated 03/2023; Policy: Food will be stored in area that is clean, dry, and free from contaminants. Policy read in part. Leftover foods will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Record review of 2017 Federal Food Code revealed that leftover food is used or discarded within 7 days.
Scoops must be provided for bulk foods such as sugar, flour, and spices.
Scoops are not to be stored in food or ice containers. Scoops are washed and sanitized on a regular basis.
MINOR
(C)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.
-The facility failed to ensure the dumpst...
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Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.
-The facility failed to ensure the dumpster lids and doors were secured.
This failure could place residents at risk of infection from improperly disposed garbage.
Findings include:
Observation on 11-07-23 at 9:00 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the top lid was wide open.
Interview on 11-07-23 at 9:05 am, with the Food Service Manager, she stated that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility.
Record review of facility's, undated, policy and procedure Dispose of Garbage and Refuse reflected all garbage will be disposed of daily and as needed throughout the day.
Procedure:. all dumpster lids and doors shall be closed or sealed at all times. Trash will be deposited into containers outside the premises.
Jan 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 12 residents (Resident #2) reviewed for order and care plans.
The facility failed to follow physician orders about use of ted hose and initial a care plan for Resident #2's use of ted hose.
This failure placed residents at risk for not receiving care according to their individually assessed needs.
Findings included:
Record review of Resident#2's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, dementia encephalopathy (brain disease or malfunction), glaucoma, (Cause of vison and blindness damaging optic nerve) history of falls, TI , (transient ischemic attack), hypertension, ( high blood pressure) insomnia ( lack of sleep) nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture.
Record review of Resident #2's admission assessment MDS dated [DATE] revealed the resident had short- and long-term memory problems, modified independence, required limited assistance of one-person for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident required supervision, bathing, and used wheelchair for mobility. The resident had a BIMS score of 4, which indicated the resident was moderately cognitively impaired.
Record review of Resident#2's care plan dated 11/03/22 revealed he had severe impaired vision and at risk for further decline in vision and eye infection related to medical condition diagnosis Glaucoma and difficulty falling asleep, feeling tired/little energy taking medication for insomnia. Goal was the resident will not have any injury during the next 90 days. Intervention included: ability to perform ADLS, decline in mobility, Sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, turned vision or hazy vision.
Record review of Resident #2's nurses progress notes dated 11/28/22 revealed resident had unwitnessed fall in bathroom, resident states he lost his balance during transfer from walker to toilet. X-rays completed 11/28/22 and 12/1/22 with no acute fracture or dislocation. Sustained R hip discoloration/hematoma. 12/6/22 resident sent to hospital for hematoma evacuation and found to have pelvic fracture.
Record review of Physician orders dated 12/09/2022 indicated apply ted hose to bilateral lower extremities (BLE) every shift for to prevent DVT (Deep venous thrombosis).
Record review of TAR (Treatment Administration Record) for 10/12/ 2022 through January 24, 2023, with initialed ( apply ted hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of ted hose.
Observation on 01/18/2023 at 9:00 AM revealed Resident #2 was in a wheelchair in his room. He had on non-slip socks.
Further observation on 1/18/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:30 PM Resident #2 had on non-slip socks on. Checked Resident #2 dressers for ted hose and there were no ted hose found.
Interview with Resident #2 on 1/18/23 at 11:00 AM, regarding any special sock he used, he had no special socks to wear and he showed the surveyor his non-slip slippers. Resident #2 only knew the non-slip sock he was wearing, he did not know about ted hose.
Observation and interviews conducted on 01/20/2023 at 10:30 AM, 2:00 PM, 3:00 PM revealed Resident #2 was in a wheelchair in his room. He had non-slip socks.
Observation on 1/20/23 at 4:00 PM, 5:30 PM, lying in bed, Resident #2 had non- slip socks on.
Interview with CNA C on 1/20/23 at 3:05 PM she said she was not aware of Resident #2's ted hose order.
Interview with Physical Therapist D on 1/20/23 at 3:10 PM she said she was not aware of ted hose order and has not seen Resident #2 wearing any ted-hose.
Interview with LVN B on 1/20/23 at 3:30 PM she said she was not aware of the ted hose order, she said Resident #2 had nonslip socks on.
Observation and interview on 01/24/2023 at 10:00 AM revealed Resident #2 in a wheelchair in his room with non-slip socks on.
Observation on 1/24/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:40 PM lying in bed, Resident #2 had non- slip socks on. In an interview at that time with Resident #2 said he have the no slip socks and had more non-slip draw in his dresser draw.
Interview with ADON LVN, on 1/24/23 at 11:40 AM the ADON LVN said the ted hose would be in the laundry room and Resident #2 always refused ted hose and she was not sure why the nurses did not document when resident refused, and the doctor/NP should be notified. ADON LVN S said she was going to check it, she then returned with TAR (Treatment Administration Record) for December 2022 and January 24, 2023, with initial on the apply ted hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of ted hose.
In an interview with the ADON on 1/24/23 at 1:24 PM she said had in-services with facility staff on documenting/notifying NP/MD when residents refused orders.
Interview with MDS coordinator, LVN A on 1/24/23 at 12:48 PM, regarding not care planning Resident #2's ted hose ordered on 12/09/22, she said she was going to check Resident #2's care plan.
Interview on 1/24/23 at 1:13 PM the MDS coordinator, LVN A said she checked Resident #2's care plan and the ted hose was not updated in Resident #2 care plan and she will be updating it now.
Record review of care plan dated 1/24/23 at 1:24 PM documented 12/9/22- I have an order for ted hose, I do refuse to wear them.
In an interview on 1/24/2023 at 2:10 PM the DON stated her expectations were to ensure the orders were followed as ordered by the physician and care plan. The DON said her MDS nurses were very good, and they just missed the care plan about ted hose.
Facility policy on care plan process requested on 1/24/23 at 3:00 PM for the DON, it was not provided till exit.
Record review of facility policy Pharmacy Services/Nursing Services orders undated indicated:
.implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1 (Resident #2) of 12 residents reviewed for professional standards.
The facility failed to follow Resident #2s physician's order for Resident #2 about the use of ted hose.
This failure could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status.
Findings Included:
Resident #2
Record review of Resident#2's face sheet revealed he was admitted to the facility on [DATE] with diagnoses; protein calorie malnutrition, dementia encephalopathy, glaucoma, history of falls, TIA, (transient ischemic attack), hypertension (high blood pressure) insomnia (lack sleep) nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture.
Record review of Resident #2's nurses progress notes on 11/28/22 revealed resident had unwitnessed fall in bathroom, resident states he lost his balance during transfer from walker to toilet. X-ray completed 11/28/22 and 12/1/22 with no acute fracture or dislocation. Sustained R hip discoloration/hematoma. 12/6/22 resident sent to hospital for hematoma evacuation and found to have pelvic fracture.
Record review of Resident #2's admission assessment MDS dated [DATE] revealed the resident had short- and long-term memory problems, modified independence, required limited assistance of one-person for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident required supervision, bathing, and used wheelchair for mobility. BIMS score of 4, which indicated the resident was moderately cognitively impaired.
Record review of Resident#2's care plan dated 11/03/22 revealed he had severe impaired vision and at risk for further decline in vision and eye infection related to medical condition diagnosis Glaucoma and difficulty falling asleep, feeling tired/little energy taking medication for insomnia. Goal was the resident will not have any injury during the next 90 days. Intervention included: ability to perform ADLS, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, turned vision or hazy vision.
Record review of Physician orders dated 12/09/2022 indicated apply ted hose to bilateral lower extremities (BLE) every shift for to prevent DVT (Deep venous thrombosis).
Record review of TAR (Treatment Administration Record) for 10/12/ 2022 through January 24, 2023, with initialed ( apply ted hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of ted hose.
Observation on 01/18/2023 at 9:00 AM revealed Resident #2 in a wheelchair in his room. He had non-slip socks on.
Observation on 1/18/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:30 PM Resident #2 had non- slip socks on. Checked Resident #2 dressers for ted hose and no ted hose found
Interview with Resident #2 on 1/18/23 at 11:00 AM, regarding any special sock he used, he had no special socks to wear and he showed the surveyor his nonslip slippers.
Observation and interview on 01/20/2023 at 10:30 AM, 2:00 PM, 3:00 PM revealed Resident #2 was in a wheelchair in his room. He had non-slip socks.
Observation on 1/20/23 at 4:00 PM, 5:30 PM, lying in bed, Resident #2 had non- slip socks on.
Interview with C.NA C on 1/20/23 at 3:05 PM regarding Resident #2's ted hose, she said she was not aware of ted hose order.
Interview with Physical Therapist D on 1/20/23 at 3:10 PM regarding Resident #2's wearing ted hose, she said she was not aware of ted hose order and has not seen Resident #2 wearing any ted-hose.
Interview with LVN B on 1/20/23 at 3:30 PM regarding Resident #2's ted hose, she said she was not aware of ted hose order, she said Resident #2 had nonslip socks on.
Observation and interview on 01/24/2023 at 10:00 AM revealed Resident #2 in a wheelchair in his room with non-slip socks on.
Observation on 1/24/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:40 PM lying in bed, Resident #2 had non-slip socks on. Resident #2 said he had the non slip socks and had more in his dresser draw.
Interview with ADON LVN on1/24/23 at 11:40 AM regarding the physician's order for Resident #2 's ted hose, resident wearing non-slip sock and noted hose in Resident #2's dresser draw. ADON, LVN said resident #2 refused the use of ted hose and it might be in the laundry. ADON LVN said she was going to look into it. At 12:20 PM ADON, LVN, brought back TAR (Treatment Administration Record) for the month of December 2022 and January 2023 with signed initials for day and night of Resident #2 using (Apply ted hose every to BLE every shift for to prevent DVT s/p fracture fall).
ADON LVN,on 1/24/23 at 1:24 PM said she had in-services with facility staffs on documenting/notifying NP/MD when resident refuse orders/treatments.
In an interview on 1/24/2023 at 2:10 PM the DON stated her expectations were to ensure the orders were followed as ordered by the physician and care plan. DON said her MDS nurses were very good, and they just missed the care plan. [NAME] hose was updated on the care plan prior to exit.
Record review of facility policy Pharmacy Services/Nursing Services orders undated indicated:
It is the policy of this facility that drug shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.
It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice for one of one resident (CR#1) received treatment and care in accordance with the professional standards of practice reviewed for falls in that:
The facility did not immediately transfer CR#1 to the hospital after an unwitnessed fall with head injury and mild bleeding to the head.
This failure placed all resident at risk of falls for not receiving timely care and treatment to improve their quality of life.
Findings Included:
CR#1
Record review of CR#!#1's admission face sheet dated 1/18/2023 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident diagnoses included type two diabetes (high blood sugar), chronic obstructive pulmonary disease (A chronic inflammatory disease that makes breathing difficult), hypertension (high blood pressure), anemia (insufficient health red blood cells), vascular dementia without behavior (memory loss), history of falling, hyperlipidemia (high levels of fat particles in the blood), recurrent depressive disorder (mood disorder), insomnia, occlusion and stenosis of unspecified carotid artery, unspecified sequelae of nontraumatic subarachnoid hemorrhage (a blood vessel bulging blood vessel that burst in the brain) and hypokalemia (low potassium).
In an interview with unidentified Family Member on 12/29/2022 at 9:00 am revealed that CR#1 had a fall, and the doctor gave orders for her to be sent to the hospital and she was not sent out until almost two hours later.
Record review of the nurse's notes dated 12/06/2022 at 6:21pm documented that CR#1 was found on the floor and was bleeding from her head with a little bit of hematoma noted with mild blood. Further record review indicated and Aassessment was done by the nurse. Notified NP, received order to send CR#1 to the hospital for CT of head.
Record review of NP D notes dated 12/06/2022 at 6:33pm documented Patient with unwitnessed fall with head injury. Order given to be sent to the hospital for evaluation.
Record review of nurse's notes dated 12/6/2023 written at 7:53 pm, documented that Family wants to call nonemergency because EMS took about one hour and a half to come through. Paramedics showed up at 7:57pm to pick up resident.
In an interview on 01/18/2023 at 2:00 pm the DON said 911 was not called because it was a nonemergency situation. She said the resident's vitals were stable and she was in no acute distress. She said they did neuro check every 15 minutes and the resident was monitored and there were no changes in CR#1's condition.
Record review of the physician's order dated 10/12/2021 revealed CR#1 had an order for Aspirin 81 mg once a day and on 10/23/2020 an order for Plavix 75 mg once a day.
Record review of the medication administration record dated 12/2022 revealed Plavix and Aspirin were given as ordered from 12/1/2022 to 12/6/2022.
In an interview on 1/18/2023 at 2:30pm CNA B said she was not the CNA who found CR#1 on the resident floor. She said she did not know it if the resident was assessed prior to transferring her to the bed as she was not in the room. She said the nurse called her to assist her to lift the resident off the floor to the bed. She said the resident was on the floor and was complaining of back and side pain. She said she assisted the nurse to put the resident in bed and she notice the bleeding to the head. She said the resident was in pain and she did not know if the resident was medicated as she was not in the room.
In an interview on 1/18/2023 at 4:01pm with LVN A she said she was not the nurse who assessed CR#1 when she fell. She said she was the oncoming nurse, and she did the documentation in the CR#1's file based on what she was told by LVN C . She said that it should be a 911 because it was a fall with head injury however it also depends on how stable the resident was. She said the NP did not give an order for a 911 call.
In an interview on 1/18/2023 at 4:46pm LVN C said she was called to CR#1's room because she was on the floor. She said the resident was yelling and was notcomplaining of pain . CR#1 was assisted to bed. She said the resident may have hit her head when she fell. She said an order for the resident to be sent to the hospital was given, but it was not given as a 911 call, so they called the non-emergency transport. She said she did neuro checks and monitored the resident, and the resident was stable.
Observation and interview with CR#1 on 1/24/2023 at 9:15am revealed the resident was in bed, she was well groomed with no offensive odor. The resident was alert and oriented with some confusion. In an interview at that time with CR#1 she said she could not remember what happened.
Record review of hospital admission notes dated 12/06/2022 written at 9:02am revealed documentation of a fall at the nursing home when she was reaching down to pick up an objective. Examination: CT scan confirms a pelvic fracture and a scalp laceration that was repaired. Further record review revealed no intercranial hemorrhage or skull fracture.
Record review of the facility's Policy and Procedures on Emergency Procedures dated 05/2007 read in part .
Policy:
It is the policy of this facility to provide appropriate and expedient care in emergency situations i.ei.e.: falls, or physical conditions.
Any changes in physical condition or behavior warrant the following nursing observations and measures:
Procedures: Initial Assessment
Objective symptoms: bleeding and swelling
Nursing Clinicals:
1.
Head injuries- Try to determine force of blow to head, observed for presence or absence of swelling, bleeding and report to physician for further instructions.
2.
Lacerations - apply pressure to stop bleeding, evaluate size of area and report to physician.
Record review of the facility's Policy and Procedures on Emergency Procedures dated 05/2007 read in part .
Policy:
It is the policy of this facility is to ensure each resident receives quality care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.
Sept 2022
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for one of one kitchen food service safety in that:
-The facility stored ...
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Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for one of one kitchen food service safety in that:
-The facility stored unlabeled food in the refrigerator and the freezer.
This failure had the potential to place residents that eat from the kitchen at risk of foodborne illness.
Findings included:
Observation and interview on 09/07/22 at 9:07 a.m., revealed 1 bag of unlabeled lettuce in the walk-in refrigerator;1 unlabeled bag of frozen waffles, and 1 unlabeled bag of fried chicken. The Lead Kitchen Aid Manager stated the bags should be labeled. He stated food needs to be labeled so that residents were not served food that had gone beyond the expiration date and that it was safe for the residents.
In an interview with the Director of Food Services Supervisor on 09/08/2022 at 12:30 p.m., she stated that the policy for storing food is when foods are placed in the fridge they are placed in bag and labeled with the prep date and the used by date. The Director of Food Services Supervisor was asked why labeling was important and she stated labeling was important to ensure that spoiled food was not served to residents.
In an interview with the DON on 09/08/2022 at 1:52 p.m., the DON stated that the facility used the Texas Food Establishment Rules or TFER as their food storage and labeling policy.
Record Review of Inservice training of Labeling and Dating of Products dated 06/21/2021 reflected in part: .If you open a package, make sure it put into a sealed bag or container and a label with an opened date and use by date
Record review of In-service training on Label and dating, rotating product conducted on 06/12/2021 read in part: . When you open a new box of product and you do not use it all, an OPEN DATE needs to go on the box and product is to be put back in the same place you got it from
A record review of the August 2021 version of the TFER reflected the following:
(b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code.
A record review of the FDA food code and the code that is relevant to the failure. https://www.fda.gov/media/110822/download
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s). Review inspection reports carefully.
- • 17 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $16,175 in fines. Above average for Texas. Some compliance problems on record.
- • Grade F (17/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Mason Creek Transitional Care Of Katy's CMS Rating?
CMS assigns MASON CREEK TRANSITIONAL CARE OF KATY an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Mason Creek Transitional Care Of Katy Staffed?
CMS rates MASON CREEK TRANSITIONAL CARE OF KATY's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Texas average of 46%.
What Have Inspectors Found at Mason Creek Transitional Care Of Katy?
State health inspectors documented 17 deficiencies at MASON CREEK TRANSITIONAL CARE OF KATY during 2022 to 2024. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 13 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mason Creek Transitional Care Of Katy?
MASON CREEK TRANSITIONAL CARE OF KATY is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 125 certified beds and approximately 95 residents (about 76% occupancy), it is a mid-sized facility located in KATY, Texas.
How Does Mason Creek Transitional Care Of Katy Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, MASON CREEK TRANSITIONAL CARE OF KATY's overall rating (2 stars) is below the state average of 2.8, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Mason Creek Transitional Care Of Katy?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Mason Creek Transitional Care Of Katy Safe?
Based on CMS inspection data, MASON CREEK TRANSITIONAL CARE OF KATY has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mason Creek Transitional Care Of Katy Stick Around?
MASON CREEK TRANSITIONAL CARE OF KATY has a staff turnover rate of 48%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mason Creek Transitional Care Of Katy Ever Fined?
MASON CREEK TRANSITIONAL CARE OF KATY has been fined $16,175 across 2 penalty actions. This is below the Texas average of $33,241. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Mason Creek Transitional Care Of Katy on Any Federal Watch List?
MASON CREEK TRANSITIONAL CARE OF KATY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.