Failure to Assist Resident with Ambulation Post-PT Discontinuation
Summary
The facility failed to maintain or improve the functional mobility of a resident who was discontinued from Physical Therapy (PT) services due to a lack of insurance coverage. The resident, who was admitted with diagnoses including muscle weakness, Wernicke's Encephalopathy, Metabolic Encephalopathy, and Cognitive Communication Deficit, required assistance with ambulation. Despite the care plan indicating that the resident could ambulate with the assistance of one staff member and a rolling walker, the facility staff did not provide the necessary assistance after PT services were discontinued. Observations and interviews revealed that the resident was not assisted with ambulation by the staff, as confirmed by the Certified Nurses Aide (CNA) Clinical Flow Sheet Documentation, which showed no ambulation in October and November 2024. The Rehabilitation Director and the Director of Nursing (DON) were unaware that the resident had not been assisted with ambulation, and the CNAs did not understand the resident's plan of care. This lack of action led to a deficiency in providing adequate care and services to maintain the resident's ability to perform activities of daily living.
Penalty
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The facility failed to implement and document restorative nursing programs intended to maintain residents' ADL abilities. Several residents with conditions such as stroke, Parkinson's disease, quadriplegia, dementia, diabetes, and a history of falls had care plans and PT discharge summaries specifying restorative interventions, including ambulation with a wheeled walker, passive stretching, and assisted range of motion exercises. The facility's restorative nursing policy required maintaining or improving functional status, and the PT Director indicated that restorative activities should be recorded on daily flow records. Review of these records over several months showed no documentation that the ordered restorative tasks were completed, and both a NA and the PT Director acknowledged that restorative nursing was not being carried out, which the administrator confirmed.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Surveyors found that the facility’s call light system did not provide audible or visual alerts beyond a computer screen at the nurse’s station, and staff often did not monitor it, resulting in prolonged response times far exceeding the facility’s 5–10 minute expectation. Several residents with hemiplegia, COPD, acute respiratory failure, multiple sclerosis, severe mobility limitations, incontinence, and continuous O2 reported waiting from tens of minutes to many hours for assistance, sometimes lying in urine or bowel for extended periods, being unable to reach their call lights, or running out of oxygen without timely help. Observations confirmed call lights active for over 30 minutes with no hallway indicators while staff sat at the nurse’s station on cell phones, and device reports documented numerous call responses taking from about 20 minutes to several hours, demonstrating a systemic failure to ensure accessible, functional call lights and prompt staff response.
Multiple residents who were dependent for toileting and frequently incontinent experienced prolonged waits for incontinence care and assistance with ADLs, with reports of call lights going unanswered for 45–90 minutes or more and residents being found soaked in urine at the start of shifts. An LPN and a CNA described chronic short staffing, especially at night, with as few as two or three aides caring for around 50–57 residents, resulting in residents routinely waiting 1–2 hours for changes. Cognitively intact residents and their families reported repeated episodes of lying in heavily saturated briefs, missed or delayed showers, and staff turning off call lights without returning, while grievance forms and shower logs documented ongoing patterns of inadequate incontinence care and hygiene that did not align with the facility’s own policy for timely care and call light response.
A resident with severe cognitive impairment and a history of hip fracture, stroke, anxiety, and depression had a care plan indicating a preference for twice-weekly baths and a need for maximum assist with bathing. Bathing records showed the resident initially received showers twice weekly, but the frequency was later reduced to once weekly after the resident moved to another unit, without documented reassessment of bathing preferences. The administrator acknowledged that preferences should have been reassessed after the move, while bath aides reported that bathing schedules are generally maintained and that they would ask new residents about their preferences. The current bathing schedule and medical record confirmed the resident was only scheduled for weekly showers, with no documented reevaluation or change in the care plan to support the reduced frequency.
A deaf resident with a communication-sensory impairment had a VRI tablet available in the room and a posted sign indicating deafness, but staff primarily relied on written notes, facial expressions, and gestures instead of using the VRI system. The resident reported that written communication was not the preferred method and that staff rarely used the VRI device. When asked by surveyors, a GNA and an LPN were unable to obtain an interpreter through the VRI system because they did not know how to operate it, despite the DON’s stated expectation that VRI be used throughout the day for this resident.
Failure to Implement and Document Restorative Nursing Programs for ADLs
Penalty
Summary
The facility failed to provide and document restorative nursing services necessary to maintain residents' abilities in activities of daily living (ADLs), as required by its own "Restorative Nursing Program" policy and federal regulations. The policy stated that the facility would safely and effectively improve or maintain a patient's functional status or prevent deterioration. The Physical Therapy Director reported that restorative activities were to be documented on the daily "Restorative Nursing Care Flow Record." However, review of these flow records from January through March 2026 for multiple residents showed no documentation that the ordered restorative tasks were completed. For one resident with a history of stroke and right-sided weakness, the care plan indicated a need for assistance with walking and transferring, and the restorative program specified walking 100 feet to dine with a wheeled walker and staff supervision, but there was no documentation of this being done. Another resident with Parkinson's disease required assistance with walking and was recommended to ambulate with staff and a wheeled walker; the restorative program also specified walking 100 feet to dine with supervision, yet no restorative care was documented. A third resident with quadriplegia and diabetes was dependent for all ADLs and had a therapy recommendation for lower extremity exercises and a restorative program for passive stretching of the right elbow, but again no restorative tasks were documented. A fourth resident with dementia, diabetes, and a history of falls, who walked with a wheeled walker and distant supervision, had a restorative program for assisted range of motion to all extremities, with no documentation of completion. A NA and the Physical Therapy Director both stated that restorative nursing was not being completed, and the Nursing Home Administrator confirmed that the facility failed to complete the restorative nursing program for these residents.
Plan Of Correction
Resident R24, R31, R78 and R93 will have a nurse/therapy evaluation to assess the restorative programs needed and POC task documentation will be created to ensure the program is completed by the CNA Resident recently discharged from Therapy will be assessed by both the Therapy department and Nursing for the need for any restorative programming. A POC task for documentation will be created to ensure the program is completed by the CNA. Staff education will be provided by the DON/Designee on the Restorative programs and the needed documentation for the programs. Education will occur on orientation and yearly. Audits will be completed by the DON/Designee on 10% of resident receiving restorative programs to ensure that the POC task documentation and the Nurse summary progress note are completed weekly times four onvarious shifts, then monthly timesthree months.Results of these audits will bepresented to the QAPI committee forreview and recommendations.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Maintain Functional Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the call light system operated as designed, that call lights were accessible to residents, and that call lights were answered in a timely manner, as required by facility policy and resident care plans. The facility’s written policy required a functioning call system at each bedside, toilet, and bathing area, with alerts either directly to staff or to a centralized location, and required staff to keep call lights within reach and respond promptly. Review of the Device Activity Report for one hall over several weeks showed an average call light response time of approximately 70 minutes, with many individual calls taking from over 20 minutes to many hours, including one documented response time of over 1,100 minutes. Staff interviews confirmed that there were no audible or visual hallway alerts, that staff relied solely on a computer screen at the nurse’s station, and that the sound on the system was often turned down. Multiple residents with significant mobility, respiratory, and ADL deficits reported prolonged waits for assistance and difficulty accessing call lights. One cognitively intact resident with hemiplegia, polyneuropathy, foot drop, generalized muscle weakness, unsteadiness, and a history of falls stated that call lights were sometimes not answered for hours, including waits of up to 5 hours, and reported having to call 911 from a cell phone because staff did not respond. Device Activity Reports for this resident documented several extended response times, including one of 350 minutes. Another cognitively intact resident with COPD, anxiety, and depression, on continuous oxygen, reported waiting up to 3 hours for call lights to be answered, including episodes where oxygen ran out and assistance was delayed until the next shift. A third cognitively intact resident with hemiplegia, COPD, acute respiratory failure with hypoxia, and a history of falls reported that staff took hours to answer call lights, that family and friends had to seek staff for help with shortness of air, and that there were times when no one came until the next shift; this resident also reported incontinence episodes because staff did not respond. Additional residents with significant physical and cognitive impairments experienced similar issues. One cognitively intact resident with hemiplegia, difficulty walking, muscle weakness, need for personal care assistance, and repeated falls reported waiting hours for call lights to be answered, sometimes being unable to reach the call light, and remaining in urine and/or bowel for hours before being changed; this resident was observed attempting to transfer from a wheelchair to bed without being able to reach the call light. A resident with severe cognitive impairment, COPD, dysphagia, incontinence, and continuous oxygen was observed in bed with the door closed, unable to reach the call light, coughing, choking on saliva, and short of breath; this resident reported often being unable to reach the call light, waiting hours for help, and lying in urine and bowel for hours when staff did not respond. Another resident with multiple sclerosis, muscle weakness, reduced mobility, hemiplegia, and need for total assistance reported that call lights were on for over 30 minutes and often for multiple hours, including one episode where a call light activated at about 1:00 a.m. was not answered until nearly 8:00 a.m., during which the resident lay in urine. During observation, this resident’s call light had been on for over 30 minutes with no hallway light or audible alert, while a CNA sat at the nurse’s station using a cell phone until prompted by another CNA to answer the light. Staff interviews corroborated that the call light system did not provide adequate audible or visual alerts and that response expectations were not met. A CNA stated that the call light system was broken, that staff only knew a call was active if they were looking at the computer screen at the nurse’s station, and that there were no lights above resident rooms or sounds in the hallways when call lights were activated. An RN reported that CNAs were expected to answer call lights within 10 minutes but that staff only knew about calls by looking at the nurse’s station screen, with no lights or sounds elsewhere, and acknowledged extended call light times. An LPN stated that policy required call lights to be answered within 10 minutes, that the computers at the nurse’s station were the only alert mechanism, and that the sound on the system was often turned down. These observations, interviews, and records demonstrate that the facility failed to maintain a functional, accessible call light system and failed to ensure timely staff response to call lights for multiple residents with significant ADL, mobility, and respiratory needs.
Failure to Provide Timely Incontinence and ADL Care Leading to Prolonged Periods in Soiled Briefs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living (ADLs), specifically incontinence care and hygiene, for multiple residents. Complaints reviewed by the State Agency alleged residents waited extended periods for call lights to be answered, resulting in residents lying in urine‑soaked briefs and experiencing poor hygiene. Staff interviews confirmed that residents were sometimes found soaked in urine at the start of shifts, with one LPN stating they could tell residents had been wet for at least 1–2 hours based on dark urine rings in briefs. The LPN also reported that the unit could hold up to 57 residents and that when staffing was reduced to three aides instead of five, residents’ care suffered and call light response and incontinence care were delayed. One resident, who was cognitively intact and dependent for toileting and transfers, reported routinely waiting at least an hour during the day and sometimes more than an hour at night for assistance with brief changes, causing them discomfort and frustration. This resident’s CNA, who worked multiple shifts, corroborated concerns about short staffing, describing assignments of approximately 16–17 residents per aide and many residents being “heavy wetters” requiring two‑person assistance. The CNA stated that at night “everybody was waiting one to two hours” for call lights to be answered and that this resident was sometimes found soaked at the start of the shift. The resident’s family member further reported that on weekends, nights, and holidays, staff frequently called off, leaving as few as two aides on the floor, and that the resident waited 1–2 hours for incontinence care; the family member also stated they had to come in to provide showers when staff did not have time. Another resident, with Parkinson’s disease and moderate cognitive impairment, was dependent for toileting and frequently incontinent. Their family member reported the resident frequently lay 45 minutes to 1 hour in a wet brief, especially at night, and that this problem recurred despite multiple grievances. A grievance documented that the resident was found soaked and crying in the morning after allegedly being left wet all night. A third resident, with severe cognitive impairment, atrial fibrillation, and a UTI, was dependent for toileting and frequently incontinent. Their family member submitted multiple grievances with photographs of heavily urine‑soaked briefs, alleging the resident’s brief was not changed at night on several occasions, that check‑and‑change schedules (every 2–4 hours) were not followed, and that the resident was typically changed only three times per day during a three‑week stay unless the family pushed for an additional change. This third resident’s grievances also described missed showers and lack of timely incontinence care despite prior assurances. The shower log for this resident’s 22‑day stay showed only four shower entries, with only two clearly initialed by staff and one scheduled shower date left blank, leaving no clear verification that showers occurred as scheduled. A fourth resident, cognitively intact and dependent for toileting hygiene and transfers, filed multiple grievances over several months describing call lights left on for 30 minutes to 1.5 hours without assistance, staff turning off call lights and not returning, and going up to a 12‑hour period without personal changing despite using the call light three times. These grievances documented ongoing concerns about extended call light wait times and lack of timely incontinence care. The facility’s own Routine Resident Care policy stated that incontinence care and call light responses were to be provided timely according to each resident’s needs, but the observations, interviews, and grievance records showed this was not consistently done for the residents involved.
Failure to Maintain Resident’s Preferred Bathing Frequency After Unit Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s activities of daily living, specifically bathing, according to the resident’s assessed needs and stated preferences. A quarterly MDS dated 1/23/26 for resident #11 showed a BIMS score of 3/15, indicating severe cognitive impairment, and diagnoses including a history of hip fracture, stroke, anxiety, and depression. The care plan dated 10/24/25 documented that the resident preferred bathing twice a week and required maximum assistance with bathing and showering. Review of the bathing record from 12/10/25 through 1/6/25 showed the resident received showers twice weekly until 1/14/26, when the frequency was reduced to once weekly. The administrator stated on 3/12/26 that the resident had moved from another unit on 12/30/25 and that shower preferences should have been reassessed and had changed, but no evidence of such reassessment was found. Bath aide interviews indicated that bathing schedules were expected to be maintained when residents moved units and that staff would typically ask new residents about their bathing preferences. The current bathing schedule and medical record confirmed the resident was scheduled for and receiving only weekly showers, with no documented reevaluation of preferences or change in the bathing schedule.
Failure to Utilize Video Remote Interpreting for Deaf Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to utilize Video Remote Interpreting (VRI) services for a deaf resident with communication-sensory impairment. A sign outside the resident’s room indicated the resident was deaf, and a VRI tablet was present in the room. Multiple staff members, including two geriatric nurse assistants and an LPN, reported that they communicated with the resident primarily through written communication, facial expressions, and gestures. The resident stated that written communication was not their preferred method of communication and reported that staff rarely used the VRI tablet. Further observations and interviews showed that staff were not effectively using the VRI system despite the facility’s expectation that it be used throughout the day during care for this resident. When the surveyor asked a geriatric nurse assistant and an LPN to obtain an interpreter through the VRI system, both were unable to do so because they did not know how to use it. The DON confirmed that the expectation was for staff to use the VRI system for this resident, and the Assistant DON acknowledged understanding of the concern when it was presented. These findings demonstrate that the resident’s preferred communication method via VRI was not being implemented in practice.
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