Garden Isle Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lihue, Hawaii.
- Location
- 3-3420 Kuhio Highway, Suite 300, Lihue, Hawaii 96766
- CMS Provider Number
- 125004
- Inspections on file
- 16
- Latest survey
- February 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Garden Isle Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide timely written notification to the LTCO when residents were transferred to acute care hospitals. Documentation showed that notifications were only sent after surveyors requested records, and the DON confirmed that the facility's policy did not include LTCO notification. This deficiency affected all sampled residents who were hospitalized.
A CNA was observed standing over a resident while assisting with feeding, despite facility policy and training requiring staff to assist residents at eye level to promote dignity. The DON confirmed that staff are educated on this expectation, and the facility's policy specifically prohibits standing over residents during meal assistance.
A resident with moderate hearing difficulty did not receive timely assistance with her hearing aids due to lack of staff training and documentation in her care plan. The resident experienced discomfort and frustration as untrained staff were unable to help, requiring intervention from a speech therapist and RN. This issue could impact all residents using hearing aids.
Several residents did not have comprehensive care plans addressing the use of specialized equipment such as tracheostomy care, bedrails, and concave mattresses. For example, a resident with a tracheostomy lacked a care plan for emergency interventions in case of dislodgement, and other residents using bedrails or concave mattresses did not have these interventions documented in their care plans. The DON confirmed these omissions during interviews and record reviews.
A resident with multiple complex medical conditions experienced a decline in mobility and ADL function after therapy services were discontinued, with family and staff interviews revealing inconsistent implementation and documentation of restorative care and range of motion exercises, resulting in the resident becoming largely bedbound and dependent on staff for transfers.
A resident with a tracheostomy did not have emergency interventions for unplanned extubation included in their care plan, and a new replacement tracheostomy tube was not kept at the bedside as required. The assigned RN initially could not locate the emergency tube in the room, and the DON confirmed both the care plan omission and the equipment's required location.
A resident who was dependent on staff for ADLs and mobility experienced ongoing pain that was not effectively identified or managed, despite clear verbal and non-verbal signs of discomfort during movement and therapy. Staff and family reported frequent pain, but pain assessments often recorded zero pain, and PRN pain medications were rarely administered, resulting in decreased participation in activities and therapy.
The facility did not complete required assessments or attempt alternative interventions before using bed rails for two residents, including one with complex medical needs. Consent forms were either incomplete or lacked necessary nursing documentation, and care plans for bed rail use were missing, as confirmed by the DON.
Licensed staff did not consistently document narcotic counts at each shift, with several entries missing required nurse signatures on the narcotic log. This failure to follow policy was confirmed by both nursing staff and management.
A nurse administered medications to a resident by crushing tablets and opening a delayed release capsule without a physician's order, mixing them with pudding for administration. The DON confirmed that such alterations require a physician order, and the facility's medication error rate during the survey was 7.14%, exceeding the acceptable threshold.
A resident with significant physical and intellectual disabilities, who is fully dependent on staff and NPO, was found with substantial plaque buildup on his teeth and had not received a dental visit in the past year. Staff interviews revealed uncertainty about appropriate oral care procedures, and documentation showed no recent dental consultations despite a prior assessment noting plaque accumulation.
The facility failed to ensure resident dignity and timely care for four residents. One resident's family member reported unmet needs for water and hygiene, while another resident's calls for attention were ignored. Two residents experienced long wait times for staff assistance, highlighting a pattern of delayed responses and inadequate care.
A resident was inaccurately coded on the discharge MDS as discharged to a short-term general hospital, while staff confirmed the resident was actually discharged home. A review of the EHR and an interview with MDSS revealed the discrepancy.
A resident with multiple disabilities and medical conditions was observed in a silent room with minimal sensory stimulation. The care plan's interventions for social contact and sensory stimulation were not consistently implemented, and the resident attended group activities infrequently and had minimal one-on-one room visits over the past six months. The Activities Manager acknowledged the deficiencies and agreed that the resident could benefit from more consistent engagement.
The facility failed to provide timely psychiatric assessment for a resident with multiple diagnoses and frequent falls, leading to numerous injuries and hospitalizations. Despite various interventions and care plan adjustments, the resident continued to experience falls, highlighting deficiencies in the facility's fall prevention and management program.
A resident with a high risk for falls experienced multiple falls, some resulting in serious injuries, due to inadequate supervision. Despite a comprehensive care plan and various interventions, the facility failed to provide consistent 1:1 supervision, as confirmed by staff and a complainant.
The facility failed to identify triggers and use trauma-informed approaches for a resident with chronic PTSD, resulting in unmet needs and potential re-traumatization. The resident's comprehensive assessment and care plan lacked information on PTSD triggers, and appropriate trauma-informed assessments were not completed until requested by the State Agency.
The facility failed to provide or obtain routine dental services for a resident, leading to sore gums and difficulties eating due to an ill-fitting denture. The resident had not seen a dentist since admission, and the last oral exam was conducted by an LPN, which is outside their scope of practice.
The facility failed to maintain accurate medical records for two residents, as a physician response form for one resident was erroneously uploaded into another resident's EHR. The DON confirmed the misfiling and noted the responsible Health Information Coordinator was unavailable for an interview.
The facility failed to ensure proper hand hygiene and contact precautions. A nurse did not perform hand hygiene between glove changes during a dressing change for a resident with pressure ulcers. Additionally, a staff member delivering lunch trays did not wear PPE when entering a resident's room on contact precautions. The Infection Preventionist and DON confirmed the resident was on contact precautions and that all staff should wear gowns and gloves before entering.
Failure to Notify LTCO of Resident Transfers/Discharges
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the Office of the State Long-Term Care Ombudsman (LTCO) for four residents who were transferred to acute care hospitals. Review of the electronic health records (EHR) for these residents showed no documentation that written notification was sent to the LTCO at the time of their transfers. Instead, the notifications were only sent on a later date, after the records were requested by surveyors. The Director of Nursing (DON) confirmed during an interview that the notifications were not sent until after the surveyors' request and acknowledged that the facility's policy did not include the requirement to notify the LTCO. The residents involved were all admitted for long-term care placement and were transferred to acute care facilities for higher levels of care. In each case, there was no evidence in the EHR that the required written notification of discharge was provided to the LTCO at the time of transfer. This deficiency was identified for all four sampled residents who experienced hospitalization, indicating a systemic failure to follow notification procedures as required.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
During a lunch observation, a Certified Nurse Aide (CNA) was seen assisting a resident with eating while standing over the resident, despite an empty chair being available in the room. The resident was sitting up in bed at the time. When questioned, the CNA stated she could either stand or sit while feeding residents and confirmed she had received training on feeding techniques. Review of the resident's electronic health record indicated a three-pound weight loss over the past month, though there had been a gradual weight increase since admission. The Director of Nursing (DON) confirmed that CNAs are expected to assist residents with meals at eye level to maintain dignity, and that staff are educated on this policy upon hire and annually. The facility's policy on meal assistance specifically states that residents should be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals. The observed practice did not align with facility policy or training expectations.
Failure to Assist Resident with Hearing Aid Use During Personal Care
Penalty
Summary
The facility failed to accommodate the needs of a resident who required assistance with her hearing aids during personal care. The resident, who was cognitively intact but had moderate hearing difficulty, reported that staff availability and lack of training among some staff members resulted in delays in receiving help with her hearing aids. During an observation, the resident indicated she had not yet received assistance that morning, and a staff member responding to her call light stated she was not trained to help with hearing aids and would need to get a nurse. Eventually, a speech therapist and a registered nurse assisted the resident. Review of the resident's care plan revealed no documentation of sensory problems or the use of hearing aids, despite her needs. The facility's policy indicated that CNAs were trained to assist with hearing aids and that such assistance should be provided in the morning upon rising. However, interviews and observations showed that not all staff were trained or able to provide this assistance, leading to discomfort and frustration for the resident. This deficiency has the potential to affect all residents who use hearing aids.
Failure to Develop and Implement Comprehensive Care Plans for Specialized Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, resulting in unmet care needs. For one resident with a tracheostomy, although the risk for complications was identified, there was no care plan addressing emergency interventions in the event of an unplanned extubation. The Director of Nursing (DON) confirmed that no interventions regarding emergency care for a dislodged tracheostomy were present in the care plan. Additionally, for another resident, the facility did not fully complete the consent form for bedrail use and failed to develop a care plan for the use of bedrails, as confirmed by the DON. Further deficiencies were observed in the care planning for residents using specialized equipment. One resident with hemiplegia and vascular dementia was observed using a concave mattress and side rails, but neither intervention was documented in the care plan, and the family was not informed about the use of the concave mattress. Another resident with dementia and a history of falls was using padded side rails as an enabler, but the care plan did not include interventions for their use. In each case, the DON acknowledged the absence of appropriate care plan documentation for these interventions.
Failure to Maintain Resident's ADL Function and Range of Motion
Penalty
Summary
The facility failed to provide necessary services to ensure a resident maintained their level of function and range of motion, resulting in a decline in the resident's ability to get out of bed. The resident, an elderly male with a history of stroke, Parkinson's disease, type 2 diabetes, Lewy body dementia, and communication deficits, was observed to be largely bedbound and dependent on staff for activities of daily living (ADLs) and mobility. Family reported that the resident had previously been able to walk with a walker but experienced a decline after therapy services were discontinued, and that he now requires a lift for transfers and remains mostly in bed. The family also expressed concerns about the lack of exercise and restorative care, noting increased stiffness and pain in the resident's legs. Review of the care plan indicated that passive range of motion (ROM) exercises and use of an ankle splint were ordered, with CNAs responsible for performing daily ROM as tolerated. However, interviews with staff revealed uncertainty about where the completion of these exercises was being documented, and it was unclear if the restorative program was being consistently implemented. Observations confirmed the resident's limited mobility and the presence of exercise instructions posted in the room, but there was no clear evidence of regular restorative care being provided or documented, contributing to the resident's functional decline.
Failure to Ensure Emergency Tracheostomy Interventions and Equipment at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not including emergency interventions for unplanned extubation in the resident's care plan. Although the resident's need for tracheostomy care and the requirement to have a new replacement tracheostomy tube at the bedside were identified, these life-saving emergency interventions were not documented in the care plan. Review of the electronic health record confirmed the absence of such interventions, and the Director of Nursing verified that the care plan did not address emergency care for a dislodged tracheostomy tube. During observation, the resident was seen in bed with a tracheostomy and was not in distress. When interviewed, the assigned RN was able to show all emergency equipment except for a new replacement tracheostomy tube, which was not present at the bedside as required but was instead found in the medication cart. The RN acknowledged that the tube should have been at the bedside and subsequently placed it there. The DON also confirmed that the emergency tracheostomy tube was supposed to be at the bedside and that holders were available for this purpose.
Failure to Identify and Manage Resident Pain
Penalty
Summary
The facility failed to identify, anticipate, and effectively manage pain for a resident who required pain management services. Despite the resident's care plan indicating a risk for pain and the need to monitor and record non-verbal signs of pain, documentation and interviews revealed that the resident frequently expressed pain during movement and activities, such as range of motion exercises and attempts to get out of bed. Staff interviews confirmed that the resident verbalized pain with movement and was reluctant to participate in activities or therapy due to discomfort and stiffness. However, the Minimum Data Set (MDS) assessment coded the resident as not having pain, and the Medication Administration Record (MAR) showed inconsistent administration of as-needed (PRN) pain medications, with scheduled pain assessments often documenting a pain level of zero despite staff and family observations to the contrary. The resident, an elderly male dependent on staff for activities of daily living and mobility, was prescribed Gabapentin for leg pain and had PRN orders for acetaminophen and acetaminophen with codeine. Review of the MAR indicated that PRN pain medications were rarely administered, and pain was not consistently documented or addressed, even though the resident exhibited clear signs of discomfort. The Director of Rehab confirmed that the resident's pain interfered with his ability to participate in therapy and wear a prescribed knee brace. The facility's pain management policy required evaluation for pain prior to, during, and after care or therapy, but this was not consistently implemented for the resident.
Failure to Assess and Document Bed Rail Use Prior to Implementation
Penalty
Summary
The facility failed to ensure that proper assessments and alternative interventions were attempted prior to the use of bed rails for two residents. For one resident with multiple complex diagnoses, including cerebral palsy, tracheostomy status, intellectual disabilities, and functional quadriplegia, bed rails were observed in use without documentation of a nursing assessment or rationale for their use, and no evidence that alternative interventions had been tried. Although a consent form was signed by the resident's representative, there was no record of ongoing quarterly assessments for the continued use of bed rails. For another resident, bed rails were in use and a consent form was signed by the resident, but the form was incomplete, lacking a nursing assessment, rationale, and documentation of alternative interventions attempted. Additionally, there was no care plan addressing the use of bed rails for this resident, and the DON confirmed these omissions. These failures resulted in the use of bed rails without the required assessments, documentation, or care planning.
Failure to Document Narcotic Counts Each Shift
Penalty
Summary
The facility failed to ensure that controlled drugs were properly accounted for at each shift by requiring licensed staff to document a count each shift. During an observation of a medication pass, a review of the narcotics log and count revealed missing nurses' signatures on the narcotic log form. Specifically, four out of forty-eight entries on the narcotic log for a one-week period were missing nurses' signatures. When questioned, a registered nurse confirmed that the narcotic count sheet had blanks and acknowledged that it is supposed to be signed at the time of the count by the nurses. Further interview with the Resident Care Manager confirmed that nurses are required to sign the narcotic log when performing the narcotic count, and that nurses are trained on this procedure. Review of the facility's policy on controlled medication storage stated that a physical inventory of all controlled substances must be conducted by two licensed nurses or approved individuals at each shift change and documented on the controlled substances count report. The observed failure to consistently document the narcotic count as required by policy led to the deficiency.
Medication Administration Without Proper Physician Orders
Penalty
Summary
During a medication pass observation, a registered nurse prepared and administered medications to a resident by crushing acetaminophen tablets and opening an omeprazole delayed release capsule, mixing each with pudding, and feeding them to the resident at bedside. The nurse stated that the resident was unable to swallow pills and believed it was acceptable to alter the medications in this manner. However, a review of the resident's electronic health record revealed there were no physician orders permitting the medications to be crushed or the delayed release capsule to be opened and administered with pudding. The Director of Nursing confirmed that nurses are required to obtain physician orders before altering medications in this way. The facility's medication error rate during the survey was calculated at 7.14%, with two errors identified out of 28 observed medication administrations.
Failure to Provide Routine Dental Services for Dependent Resident
Penalty
Summary
A resident with multiple complex medical conditions, including cerebral palsy, tracheostomy status, intellectual disabilities, and functional quadriplegia, was observed to have a thick orange-colored buildup on his front teeth while in bed. The resident is dependent on staff for all care and is NPO (nothing by mouth). Review of the electronic health record revealed no documentation of a dental visit or consultation within the past year, despite the resident's need for routine dental care. The last documented dental assessment, completed by a nurse several months prior, noted plaque buildup, but no follow-up dental visit was arranged. Interviews with staff indicated uncertainty regarding the provision of oral care for the resident, particularly concerning the use of toothpaste due to his NPO status. The CNA reported using a dry brush or wipes for oral care, and the RN stated that dental visits are arranged only if needed, with no evidence of a recent appointment. The DON confirmed that the resident had not seen a dentist in the past year and cited challenges related to the resident's physical condition and wheelchair use as barriers to accessing dental services.
Failure to Ensure Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure the resident's right to a dignified existence and treat each resident with respect and dignity for four residents. Resident 60, who has severe cognitive impairment and is dependent on staff for toileting, was observed to have unmet needs for water and hygiene. The resident's family member reported having to frequently request water and ice from the nursing station, where staff were often unavailable. Additionally, the family member expressed frustration over the resident not being changed all morning, resulting in a soiled brief. These observations indicate a lack of timely and adequate care for Resident 60, compromising their dignity and well-being. Another incident involved Resident 35, who was observed calling out for attention multiple times without immediate response from nearby staff. The Activities Manager acknowledged that staff should have responded promptly. Furthermore, Residents 30 and 67 reported long wait times for staff to respond to call lights, with one instance of waiting over an hour for assistance. Both residents are dependent on staff for various activities of daily living. These findings highlight a pattern of delayed responses and inadequate attention to residents' needs, undermining their dignity and respect.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure the resident assessment accurately reflected the resident's status for one of three sampled for closed records. A resident was coded on the discharge Minimum Data Set (MDS) as discharged to a short-term general hospital, but staff confirmed the resident was actually discharged home. A review of the resident's Electronic Health Record (EHR) and an interview with Minimum Data Support Staff (MDSS) revealed that the discharge MDS did not accurately reflect the resident's discharge status, as the resident was discharged home, not to a hospital.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to ensure an ongoing resident-centered activities program that met the needs of a resident with cerebral palsy, aphasia, intellectual disabilities, and functional quadriplegia. The resident, who also has a tracheostomy and gastrostomy, was observed lying in bed in a silent room with minimal sensory stimulation. The resident's television was off and positioned in a way that obstructed its view when the privacy curtain was closed. The care plan for the resident included interventions for social contact and sensory stimulation, but these were not consistently implemented. The resident was not observed out of his room during the survey period, and there were no family photos at his bedside despite having family members. The activity logs revealed that the resident attended group activities infrequently and had minimal one-on-one room visits over the past six months. The Activities Manager acknowledged the lack of consistent social and sensory stimulation for the resident and agreed that the resident could benefit from music therapy and visual stimulation. The manager also noted that the resident's TV should be moved closer and turned on more frequently but could not identify specific TV shows or music that the resident enjoyed. This lack of consistent engagement placed the resident at risk of a decline in psychosocial well-being and comfort.
Failure to Provide Timely Psychiatric Assessment for Resident with Frequent Falls
Penalty
Summary
The facility did not provide timely psychiatric assessment for one resident, identified as R46, who had an increasing number of falls, including a recent fracture that required surgery and hospitalization. R46 was admitted with multiple diagnoses, including stroke, adjustment disorder, atrial fibrillation, atherosclerotic heart disease, high blood pressure, anxiety, restlessness, agitation, and frequent falls. Despite being identified as high risk for falls using the John Hopkins Fall Risk Assessment Tool, the resident continued to experience numerous falls throughout their stay. The comprehensive care plan included various interventions such as 1:1 supervision when restless, residing in a room near the nurse's station, and the use of a low bed and fall mat. However, these measures did not prevent the falls, and the resident continued to fall frequently, both witnessed and unwitnessed, leading to further injuries and hospitalizations. The facility's policy on fall prevention and management emphasized the need for a dynamic treatment plan, interdisciplinary team involvement, and regular reassessments, but these measures were not effectively implemented for R46. The Director of Nursing acknowledged the lack of psychiatric services on Kauai and the efforts to coordinate care with services on Oahu. Despite these efforts, the facility failed to provide timely psychiatric assessments, which could have potentially mitigated the resident's fall risk.
Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility did not provide adequate supervision for one resident, identified as R46, who was at high risk for falls. R46 had a history of multiple falls, some of which resulted in serious injuries requiring hospitalization and surgery. Despite being identified as high risk for falls through the John Hopkins Fall Risk Assessment Tool and having a comprehensive care plan in place, R46 continued to experience numerous falls, both witnessed and unwitnessed, over several months. The care plan included various interventions such as 1:1 supervision as needed, residing near the nurse's station, use of a low bed and fall mat, and sensor alarms, but these measures were insufficient to prevent the falls. Interviews with staff and the complainant revealed concerns about inadequate staffing levels to provide the necessary supervision for R46, with staff indicating that 1:1 supervision was not consistently provided throughout the shift. The facility's policy on Fall Prevention and Management emphasized the importance of a dynamic treatment plan, interdisciplinary team involvement, and regular reassessments. However, the implementation of these policies was inadequate in R46's case. The resident's frequent falls, despite the interventions listed in the care plan, indicate a failure to provide the necessary supervision and safety measures. The complainant also reported being told to help watch the resident or hire someone to do so, highlighting the facility's inability to ensure adequate supervision. Staff interviews corroborated the complainant's concerns, with some staff members expressing that there were not enough personnel to provide 1:1 supervision as required.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to identify triggers that may cause re-traumatization and consistently use trauma-informed approaches when caring for a resident with chronic PTSD. The resident, a male with a history of PTSD from Vietnam, was admitted for long-term care with multiple diagnoses including Parkinson's disease, depression, anxiety, dementia, and insomnia. Despite the resident's history of PTSD and specific needs, the comprehensive admission assessment and care plan did not include information on potential triggers or strategies to reduce re-traumatization. Additionally, the facility did not review the resident's pre-admission PTSD history or address his unique sleeping habits that help him feel secure. The facility's Trauma Informed Care policy required a Trauma Informed Observation progress note and the development of a care plan based on identified trauma events and triggers. However, the facility did not complete the appropriate trauma-informed assessment for the resident until after the State Agency's request. The resident confirmed that he had not received counseling for his PTSD since admission and expressed a desire to continue his counseling at the Vet Center. The Social Services Associate acknowledged that the resident's pre-admission history should have been reviewed and included in the trauma-informed care assessment, and that the assessment should have been conducted with the resident's wife present due to his dementia and forgetfulness.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for a resident, leading to unmet dental needs. The resident, a male with no natural teeth, complained of sore gums and an ill-fitting denture. He reported not having seen a dentist since his admission and described difficulties eating due to the lack of a suitable diet. The resident's electronic health record showed no dental consultations, and the last oral exam was conducted by an LPN, which is outside the scope of their practice according to the facility's policy. The facility's Dental Services policy mandates providing or obtaining routine and emergency dental services, including annual oral cavity inspections, dental cleanings, and denture fittings. However, the resident had not received these services, highlighting a failure to adhere to the policy. This deficiency has the potential to affect all residents in the facility, as it indicates a systemic issue in providing necessary dental care.
Inaccurate Medical Record Maintenance
Penalty
Summary
The facility failed to maintain an accurate medical record for two residents. During a record review, it was found that a document for one resident was erroneously uploaded into another resident's Electronic Health Record (EHR). Specifically, a physician response form for one resident, which addressed questionable orders for Acetaminophen, was incorrectly filed in another resident's EHR. The Director of Nursing (DON) confirmed the misfiling and noted that the Health Information Coordinator responsible for the error was not available for an interview at the time.
Failure to Follow Hand Hygiene and Contact Precautions
Penalty
Summary
The facility failed to ensure that staff followed proper hand hygiene and contact precautions practices. During a dressing change for a resident with multiple pressure ulcers, a registered nurse did not perform hand hygiene between glove changes. The nurse removed dirty gloves, picked up clean gloves, and started to put them on without using hand sanitizer until prompted by the surveyor. The nurse and another staff member later confirmed that hand hygiene was not performed as required by the facility's policy, which mandates hand hygiene before donning and after doffing gloves and personal protective equipment (PPE). Additionally, a staff member delivering lunch trays did not wear the required PPE when entering a resident's room who was on contact precautions. The staff member was unaware of the reason for the contact precautions and did not check with the nurse before entering. The resident's electronic health record documented a wound on the back, but there was no order for contact precautions in the physician's orders. The Infection Preventionist and Director of Nursing confirmed that the resident was on contact precautions and that all staff should be wearing gowns and gloves before entering the room, including when delivering meal trays.
Latest citations in Hawaii
A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
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