Marine Creek Nursing And Rehabilitation

F-F695 The facility failed to ensure that a resident who needed tracheostomy care, was provided such care consistent with professional standards of practice by over-inflating Resident #1's tracheostomy tube cuff, causing changes to the resident's T1 and T2 vertebrae, and placing him at risk of malnutrition, aspiration/pneumonia, and infection.

Interventions:

As of [DATE REDACTED], resident #1 remains admitted to the hospital.

On [DATE REDACTED] twenty-four tracheostomies were checked by the DON, Regional Compliance Nurse, and Lead RT for proper inflation not to exceed 25 cm H2O per manufacture recommendation. There were twenty-two with inflatable cuffs and they were all within the guidelines.

The medical director was notified of the immediate jeopardy by the administrator on [DATE REDACTED].

AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on [DATE REDACTED] to discuss

the immediate jeopardy and subsequent plan of removal.

In-services

As of [DATE REDACTED], all Respiratory Therapists will be in-serviced 1:1 by the Lead Respiratory Therapist on the following: All staff not present will not be allowed to work their next shift until they are in-serviced. All PRN and agency staff will be in-serviced prior to the start of their next scheduled shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 675779 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675779 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 o Abuse and Neglect- Over inflating a cuffed tracheostomy could cause a change in condition which include injury, unresponsiveness, difficulty swallowing, swelling, neck distention, and deceased appetite. Level of Harm - Immediate jeopardy to resident health or o Trach cuffs will only be filled to manufacture recommendations. Respiratory therapist to notify physician safety immediately if more than 25 cm H2O is required in trach cuff. No exceptions unless documented by the Pulmonologist. Residents Affected - Few o If the manufacture recommendation is not sufficient for an individual's tracheostomy the Pulmonologist will be contacted for oversight and direction. If the Pulmonologist cannot be reached the resident will be sent out 911.

Monitoring:

The Lead Respiratory Therapist will observe 5 trach cuff inflations per week to ensure correct pressure has been applied according to manufacture or pulmonologist recommendations. This monitoring will continue weekly for 6 weeks.

The DON will ask 3 Respiratory Therapists per week, what would you do if a trach cuff needed more than 25 cm H2O? Did respiratory therapist respond appropriately? This monitoring will continue weekly for 6 weeks.

Monitoring of POR on [DATE REDACTED] included the following:

Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #9's, who all had tracheostomies were care planned and receiving appropriate tracheostomy care per physician orders and/ or recommended standards.

Record review of 1:1 in-service on abuse/neglect, proper inflation of tracheostomy cuffs, and notifying the physician, dated [DATE REDACTED], reflected RTs were in-serviced by the Regional Compliance Nurse.

Review of document provided by the Administrator, dated, [DATE REDACTED], reflected tracheotomy audits had completed on residents with tracheostomies by the Regional Compliance Nurse, DON, and Lead RT.

Record review of QAPI sign-in sheet, dated [DATE REDACTED], revealed a meeting was held to review the company's tracheostomy cuff inflation policy and need for an immediate change process.

Interviews on [DATE REDACTED] from 11:30 AM to 3:30 PM were conducted with Lead RT, RT C (6a-6p shift), RT D (6a-6p shift), RT E (6p-6a shift), RT F (6A-6P shift), and RT G (6p-6a shift). All interviewed staff were able to provide competency regarding in-services over abuse/neglect, following manufacturer's recommendations for inflation of tracheostomy cuffs, and notifying the physician if a resident requires more than the recommended amount of pressure for inflation and any other concerns. The Lead RT stated it was her responsibility to oversee the care being provided by the RTs and to monitor tracheostomies daily.

Observation on [DATE REDACTED] at 1:15 PM-1:25 PM of Residents #5, #7, and #8 tracheostomy care revealed the cuffs had the recommended amount of pressure and no concerns with care provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 675779 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675779 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 An Immediate Jeopardy (IJ) was identified on [DATE REDACTED]. An IJ Template was provided to the facility on [DATE REDACTED] at 3:30 PM. While the Immediate Jeopardy was removed on [DATE REDACTED] at 3:23 PM, the facility remained out of Level of Harm - Immediate compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal jeopardy to resident health or harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and safety effectiveness of their plan of removal.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 675779