Avista Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 2901 Galaxy Drive, Saginaw, Michigan 48601
- CMS Provider Number
- 235139
- Inspections on file
- 21
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avista Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed multiple deficiencies in the kitchen, including dirty and damaged food service equipment, improperly cleaned trays and plate warmers, and unsanitary storage conditions in the walk-in cooler and freezer. Wet and soiled items were found among clean supplies, and significant ice buildup in the freezer led to improper door closure and water accumulation, with staff acknowledging the ongoing issue.
Surveyors found that medications, including multi-dose inhalers, insulin pens, and ophthalmic drops, were stored in medication carts without required open or expiration dates, and some medications belonged to discharged residents. Nursing staff acknowledged the lack of proper dating and uncertainty about policy requirements, and loose, unidentified tablets were also found in the carts. These practices did not follow the facility's policies for medication storage and labeling.
Surveyors observed multiple infection control breaches, including a kitchen staff member with exposed hair and artificial nails, an LPN failing to use proper barrier precautions and hand hygiene during wound care for two residents, and a resident on contact precautions left with soiled linen in the room and no accessible soap for hand hygiene. These actions were not in compliance with facility policy and infection prevention standards.
Two residents did not receive timely wound care as ordered, with wound dressings remaining unchanged for multiple days despite documentation indicating daily treatments were completed. Staff interviews and record reviews revealed discrepancies between treatment records and actual care provided, resulting in missed wound care for residents with complex medical conditions.
Surveyors identified that the facility failed to implement and monitor pressure ulcer prevention measures for two residents. One resident developed a facility-acquired penile erosion due to improper urinary catheter management, with observations noting taut tubing and resident-reported pain. Another resident, dependent on staff for care, was found with a non-functional air mattress due to a bent plug, and there was no documentation or process in place for staff to check the mattress settings. These deficiencies were confirmed through observation, interviews, and record review.
A resident with multiple medical conditions, including dementia and diabetes, was observed multiple times with her trapeze device for bed mobility out of reach, despite her care plan indicating its use. Staff were unsure if the device had been repositioned during care and not returned to an accessible position, resulting in the resident being unable to access the assistive device as needed.
A resident with chronic respiratory conditions was observed to have their nebulizer mask left out on a plastic bag and later stored in a nightstand drawer, rather than in a storage bag as required by facility policy. Staff interviews confirmed the mask should have been bagged after drying, but this was not done following multiple treatments.
Surveyors observed that the facility installed a deep-fat fryer next to a new gas stove without the required baffle plate, had a shelf protruding over stove burners, failed to ensure appliances were returned to approved locations, and did not re-evaluate the kitchen fire suppression system after equipment changes, all in violation of NFPA 96 standards.
The facility did not provide documentation showing that semiannual visual inspections of fire alarm initiating devices were completed as required by NFPA 72. This was confirmed during interviews with the Maintenance Director and Regional Director.
A quarterly inspection revealed a water flow switch failure in the facility's sprinkler suppression system, and the facility did not provide documentation that this deficiency was corrected as required by NFPA standards. This was confirmed during record review and interviews with facility leadership.
Surveyors found that cross corridor smoke barrier doors near two resident rooms did not close properly when tested, failing to prevent the passage of smoke as required by NFPA 101. This deficiency was confirmed with the Maintenance Director and could affect about 25 occupants during a fire emergency.
The facility failed to maintain safe cold holding temperatures for milk, with observations showing milk temperatures exceeding the safe limit of 41°F. The Dietary Manager confirmed that the cooler was left open during meal service, contributing to the issue. Temperature logs were incomplete and did not routinely check serving temperatures, leading to multiple instances of milk being served at unsafe temperatures.
The facility did not adequately address or document responses to grievances reported during Resident Council meetings, affecting residents' quality of life. Residents expressed that their concerns were not followed up on, and a review of notes from June 2023 to May 2024 showed a lack of documentation of responses to specific issues. The facility's policy requires written responses to grievances, but the Activities Director confirmed no documentation of follow-up. Grievances included issues with food, therapy, nursing, social services, housekeeping, and maintenance.
The facility failed to honor residents' food choices and maintain food palatability and temperature, leading to dissatisfaction and hunger. A resident reported receiving disliked food items and inadequate portions, while a Resident Council meeting highlighted issues with meal timeliness, flavor, and temperature. Observations confirmed missing condiments and improperly chilled beverages.
A facility failed to assess and document a resident's incompetency before enacting a Durable Power of Attorney (DPOA), leading to medical decisions being made without legal documentation. The resident, with severe cognitive impairment, had discrepancies in advance directive documentation and informed consent for psychoactive medications. The facility's policy was not provided by the survey's conclusion.
The facility failed to provide adequate hygiene care and documentation for two residents. A female resident with severe cognitive impairment was observed with long facial hair, despite documentation indicating completed personal hygiene tasks. Staff interviews revealed a lack of specific documentation for female shaving refusals. Another resident, dependent on staff for daily living activities, was observed in bed for an extended period, contrary to their care plan. The Director of Nursing acknowledged these issues.
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. One resident with severe vascular dementia and right-sided hemiplegia had no care plan for Restorative Nursing or ROM exercises, while another resident with anoxic brain damage and impaired ROM had multiple unused splints and braces. Interviews revealed the facility was developing a Restorative Nursing Program but had not yet implemented it.
A resident suffered a fractured tibia and fibula after sliding out of their wheelchair during transport due to a faulty seat belt in a facility van. The transport staff, a recently transitioned CNA, lacked adequate training in securing residents. The facility failed to conduct a thorough investigation or report the incident, and discrepancies were found in staff accounts of the event.
A facility failed to provide proper catheter care and complete UTI treatment for two residents. One resident's catheter was unsanitary and not secured, while another experienced a delay in receiving prescribed antibiotics for a UTI, receiving only 17 of 18 doses. The facility lacked documentation of peri-care audits, indicating deficiencies in infection control practices.
A resident with a PICC line did not receive timely dressing changes as required by facility policy and healthcare provider orders, leading to concerns about care and potential infection risk. The resident's dressing was outdated, and an LPN failed to address this during an IV infusion check. The MAR inaccurately recorded a dressing change, and during an observed dressing change, the ADON compromised sterile technique. The DON confirmed the discrepancies and acknowledged the need for corrective action.
Failure to Maintain Sanitary Food Service Equipment and Storage Areas
Penalty
Summary
The facility failed to maintain food service equipment and ensure sanitary conditions in the kitchen, as observed during a kitchen tour. Specific deficiencies included a refrigerator with a ripped door seal and food particles in the door corner, as well as streaks and smears on the exterior that were easily removed when wiped. Seven meal trays used for serving residents had jagged edges, and four plate warmers that were supposed to be clean had dried food particles. Five steam table lids had bent corners and dried food residue. The garbage can lid had a white substance, and a rack with clean, ready-to-use pans and lids was found with wet and dirty items. Additionally, a trolley in the back kitchen hallway had a resident's used meal tray and an unknown pink substance on its exterior, contrary to staff procedures for tray placement. Further issues were identified in the walk-in cooler and freezer. The cooler had a trail of water leading into the freezer, and the freezer itself had thick snow and ice buildup on the door frame, ceiling, and above the fan, which prevented the door from closing properly. There was condensation and ice on the plastic curtains and door frame, and during a delivery, boxes were observed with wet marks from ceiling drips. The freezer floor was visibly wet, with water tracking back into the cooler. The Maintenance Director acknowledged awareness of the ice and snow buildup, attributing it to dietary staff not closing the freezer door tightly. The facility's sanitization policy requires all equipment and utensils to be washed and sanitized, and for manually washed items to air dry whenever practical, which was not consistently followed.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and labeling practices across all four medication carts reviewed. Observations revealed that multi-dose medications, such as inhalers, insulin pens, ophthalmic drops, and nasal sprays, were frequently found without required open dates or expiration dates. In several instances, medications belonging to residents who had been discharged remained in the carts, and loose, unidentified tablets were discovered in various drawers. These findings were corroborated by interviews with nursing staff, who acknowledged the lack of proper dating and, in some cases, uncertainty regarding the facility's policy on medication dating. Record reviews of the facility's 'Storage of Medications' and 'Medication Administration' policies indicated that medications and biologicals are to be stored securely and dated upon opening, with certain medications requiring a shorter expiration period once opened. Despite these policies, surveyors observed opened containers of blood sugar testing strips, insulin pens, and other multi-dose medications without any indication of when they were opened or when they should be discarded. Staff interviews confirmed that these items were in use without adherence to the documented procedures for dating and discarding. The deficiency was further evidenced by the presence of medications for residents no longer residing in the facility, as well as loose tablets found in medication carts without identification or proper storage. Staff members, including RNs and LPNs, were unable to provide consistent explanations for the lack of dating or the continued presence of medications for discharged residents. These actions and inactions directly contravened the facility's own policies and accepted professional standards for medication storage and labeling.
Infection Control Failures in Kitchen, Wound Care, and Isolation Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed during the survey. In the kitchen, the Dietary Manager was seen wearing a hair net that did not fully cover her hair, with long tendrils exposed on both sides of her face, and was also found to have long artificial nails. Both of these actions were in direct violation of the facility's policy, which requires hair nets to fully cover hair and prohibits artificial nails for staff involved in food preparation. The Dietary Manager acknowledged awareness of these requirements during interviews, and the Infection Control Nurse and Director of Nursing confirmed that these practices were not in compliance with CDC recommendations and facility policy. During wound care observations, an LPN failed to use enhanced barrier precautions when assessing a resident's PEG tube site, not donning a gown or gloves before lifting the resident's shirt and breast to access the tube. In another instance, the same LPN and a CNA performed wound care on a different resident with open stage III pressure ulcers. After cleaning bowel material from the resident's buttock region, neither the LPN nor the CNA changed gloves before proceeding with wound care, and the LPN did not perform hand hygiene before donning new gloves. The LPN also reached into her uniform pocket with gloved hands to retrieve a pen, further increasing the risk of cross-contamination during the dressing change. Additionally, a resident on contact precautions for C. difficile was found in a room with a pile of soiled linen, including sheets and blankets with dried red substances, left atop a recliner. The resident reported the linen had been changed that morning, but it had not been removed from the room. The soap dispenser in the room was also found to be non-functional, as the soap bag was not properly engaged, making hand hygiene inaccessible for staff and visitors. The Infection Control Nurse confirmed both the improper storage of soiled linen and the lack of accessible soap in the resident's room.
Failure to Provide Timely and Documented Wound Care
Penalty
Summary
The facility failed to assess, monitor, and document wound care in a timely manner for two residents, resulting in missed treatments. For one resident, an occlusive dressing on the left elbow was observed to be dated several days prior, despite treatment administration records indicating that daily wound care had been completed. Interviews revealed that the nurses who signed off on the treatments were not the ones who actually performed them, and the old dressing remained in place, indicating that the required wound care was not provided as documented. The resident had diagnoses including aphasia, hypertension, and stroke, and required assistance with activities of daily living. For another resident, a wound dressing on the right foot was found to be dated two days prior, even though physician orders required daily dressing changes. The resident had a complex medical history including sepsis, diabetes, atrial fibrillation, Guillain-Barre Syndrome, Bell's Palsy, and borderline personality disorder. The discrepancy in dressing dates and documentation suggested that at least one daily wound care treatment was missed, despite staff initially believing the dressing was dated incorrectly.
Failure to Implement and Monitor Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement preventive pressure ulcer measures and prevent new ulcers from developing for two residents. For one resident with a urinary catheter, observations revealed a left-sided penile erosion measuring 3 to 3.5 cm in length, attributed to the catheter. The catheter tubing was noted to be taut from the penis head to the left thigh, and the resident reported pain at the site. The resident also stated that the leg bag would become heavy and pull on the tubing, causing discomfort. During the observation, the LPN did not use hand sanitizer before donning gloves and had long artificial nails with jewelry attachments. The wound was confirmed to be facility-acquired, and the wound care nurse acknowledged the difficulty in measuring the wound accurately due to its location and the limitations of photographic documentation. The DON confirmed the erosion was caused by the catheter and was being treated in-house. For another resident, the facility failed to ensure the proper functioning of a prescribed air mattress intended to prevent pressure ulcers. The resident, who was dependent on staff for activities of daily living and had multiple comorbidities including diabetes, stroke, and muscle weakness, was observed in bed with an air mattress that was not plugged in and not functioning as intended. The plug was found to have a bent prong, preventing it from being plugged in. There was no documentation in the physician's orders or care records requiring staff to check the air mattress for functionality or to ensure it was set to the correct alternative pressure setting. Staff interviews confirmed that there was no established process for documenting checks of the air mattress prior to the surveyor's intervention. These deficiencies were identified through direct observation, staff and resident interviews, and record reviews. The lack of preventive measures and monitoring contributed to the development of a facility-acquired pressure injury in one resident and the risk of pressure ulcer development in another, both of whom were dependent on staff for care and at high risk for skin breakdown.
Trapeze Device Not Accessible for Bed Mobility
Penalty
Summary
A deficiency was identified when a resident's trapeze, an assistive device for bed mobility, was not accessible on multiple occasions. Observations showed that the trapeze was flipped over the stabilization bar and out of the resident's reach while she was in bed. When asked, the resident confirmed she was unable to reach the device and demonstrated her inability to access it. The care plan indicated a preference for the trapeze to assist with bed mobility, and records confirmed the resident was assessed as safe to use it. Despite the care plan and assessment, the trapeze remained inaccessible during several observations, and staff were unsure if it had been repositioned during care and not returned to an accessible position. The resident's medical history included diabetes, dementia, atrial fibrillation, and hypertension. The deficiency was based on the failure to ensure the assistive device was within reach as required to maintain or improve the resident's range of motion and mobility.
Failure to Properly Store Nebulizer Mask After Use
Penalty
Summary
A deficiency was identified when a resident who required nebulizer treatments for chronic heart and lung disease did not have their nebulizer mask stored in accordance with facility policy. The resident, who had multiple diagnoses including chronic respiratory failure, Alzheimer's Disease, and required assistance with all activities of daily living, was observed to have their dry nebulizer mask left on top of a plastic bag next to the treatment machine, rather than being placed inside a storage bag as required. This observation was made several hours after the last documented treatment, indicating the mask had sufficient time to dry and be stored properly. A subsequent observation found the nebulizer mask and attached oxygen tubing stored inside a closed nightstand drawer, with the tubing hanging out, rather than in a designated storage bag. During interviews, the resident confirmed the timing of the last treatment, and the Clinical Nurse Manager acknowledged that nebulizer masks should be stored in a bag when not in use. These findings demonstrate that staff did not follow the facility's nebulizer process policy regarding the storage of respiratory equipment.
Noncompliance with NFPA 96 Standards for Kitchen Equipment Installation
Penalty
Summary
The facility failed to ensure that cooking facilities were installed and protected in accordance with NFPA 96 standards. Observations revealed that a newly installed deep-fat fryer was placed within 16 inches of the surface flame of a new six-burner gas stove, without the required steel or tempered glass baffle plate of at least 8 inches in height between the fryer and the stove. Additionally, a shelf was found protruding over the stove top burners, which could obstruct the hood suppression system as per NFPA 96 requirements. The facility also did not provide approved methods to ensure that cooking appliances are returned to their approved design locations. Further, after the installation of the new gas stove and the addition of the deep-fat fryer, the facility did not have the kitchen Ansul fire extinguishing system re-evaluated as required by NFPA 96. These deficiencies were confirmed through interviews with the Maintenance Director and Regional Director at the time of observation. No information about specific residents or their conditions was provided in the report.
Failure to Document Semiannual Fire Alarm System Inspections
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 72. During a record review, it was found that there was no documentation available to show that the required semiannual visual inspection of the fire alarm initiating devices had been completed, as specified by NFPA 72, section 14.3. This lack of documentation was confirmed during interviews with both the Maintenance Director and the Regional Director at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Document Correction of Sprinkler System Water Flow Switch Deficiency
Penalty
Summary
The facility failed to provide documentation that a water flow switch deficiency, identified during a quarterly sprinkler inspection, had been corrected as required by NFPA 72, 17.12.2. During a review of facility records, it was found that the sprinkler suppression system inspection report indicated the water flow switch failed during testing, and there was no evidence that this issue had been addressed. This finding was confirmed through interviews with the Maintenance Director and Regional Director at the time of the record review. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Maintain Smoke Barrier Door Functionality
Penalty
Summary
Surveyors observed that the facility failed to maintain the proper operation of smoke barrier doors in accordance with NFPA 101 requirements. Specifically, during an inspection, the cross corridor doors near resident rooms #205 and #208 did not close properly when tested, which would prevent them from stopping the passage of smoke as required. These deficiencies were confirmed through interviews with the Maintenance Director at the time of observation. Approximately 25 occupants could be affected by this failure in the event of a fire emergency, as the doors did not function as intended to provide a smoke barrier.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate cold holding temperatures for potentially hazardous food, specifically milk, in the kitchen, which increased the potential for foodborne illness among the 79 residents receiving meal services. During an observation, the surveyor noted that the two-door reach-in cooler was left open during meal service, which was confirmed by the Dietary Manager (DM) as a normal practice. The temperature of the milk was found to be 55 degrees Fahrenheit, exceeding the safe temperature limit of 41 degrees Fahrenheit as per the 2017 U.S. Public Health Service Food Code. The DM acknowledged that such milk would typically be discarded. Further observations revealed that milk served to residents in the dining room and on tray carts also exceeded safe temperature limits, with readings between 47.5 and 52.3 degrees Fahrenheit. The facility's temperature logs lacked documentation for certain days and did not include start or discard times for milk, nor did they routinely check serving temperatures. The logs showed multiple instances of milk being served at unsafe temperatures, ranging from 44 to 54 degrees Fahrenheit. The facility's Food Preparation and Service Policy emphasized maintaining potentially hazardous foods below 41 degrees Fahrenheit to prevent the growth of harmful pathogens, which was not adhered to in this case.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately address and document responses to grievances reported during Resident Council meetings, affecting the quality of life for residents. During a Resident Council meeting, residents expressed that their concerns were not being followed up on or resolved, with staff only asking generalized questions about whether issues had been resolved. A review of Resident Council notes from June 2023 to May 2024 revealed that while residents voiced concerns, the notes did not specify issues with specific disciplines, nor was there documentation of responses to these concerns at subsequent meetings. The facility's policy on grievance procedures requires that all grievances, complaints, or recommendations from resident or family groups be considered and responded to in writing, including the rationale for the response. However, the Activities Director confirmed that there was no documentation of follow-up on resident concerns from Resident Council meetings. Specific grievances included issues with food palatability, therapy services, nursing care, social services, housekeeping, and maintenance, among others, with no documented resolutions or updates provided to the residents.
Deficiencies in Food Service and Resident Satisfaction
Penalty
Summary
The facility failed to ensure that residents' food choices were honored, food was palatable, and an adequate amount of food was offered. During a noon meal observation, residents were served chili and salad without the Texas toast that was listed on the menu. The Dietary Manager acknowledged that the toast was overlooked and mentioned that staffing issues have delayed the implementation of a system to take residents' meal preferences. Resident #47, who is alert and able to make healthcare decisions, reported receiving food items he disliked, such as oatmeal, and not being informed about alternative menu options. The resident also expressed dissatisfaction with the portion sizes and the temperature of the food. During a Resident Council meeting, attendees expressed concerns about the timeliness, flavor, and temperature of meals, as well as inconsistent portion sizes and accompaniments. An observation of a lunch meal revealed missing condiments and accompaniments, and the beverages were not served at a cold temperature. The Dietary Manager confirmed the issues with food temperature during subsequent observations. These deficiencies resulted in residents feeling anger, frustration, and hunger.
Failure to Ensure Proper Incompetency Assessment Before Enacting DPOA
Penalty
Summary
The facility failed to ensure proper assessment and documentation of incompetency before enacting a Durable Power of Attorney (DPOA) for a resident, leading to medical decisions being made without legal documentation of incompetency. Resident #28, who was admitted with diagnoses including dementia with behavioral disturbance, was found to have a DPOA enacted before a formal determination of incompetency by two physicians. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment, requiring supervision for Activities of Daily Living (ADL). The review of the resident's records revealed discrepancies in the documentation of advance directives and the signing of informed consent for psychoactive medications. The Advance Directives/Medical Treatment Decisions form was improperly completed, lacking the resident's signature and only signed by a facility LPN. Additionally, the Informed Consent for Psychoactive Medications form for Seroquel was signed by a family member before the resident was deemed incompetent. Interviews with the Social Services Director and the Administrator confirmed these findings, and the facility's policy/procedure was not provided by the conclusion of the survey.
Deficiencies in Hygiene Care and Documentation
Penalty
Summary
The facility failed to provide adequate hygiene care for two residents, resulting in deficiencies in personal grooming and documentation. Resident #28, a female with severe cognitive impairment and multiple health issues, was observed with long, visible facial hair on two separate occasions. Despite the documentation indicating that personal hygiene tasks were completed, the facial hair was not removed. Interviews with staff revealed that there was no specific area in the electronic medical record (EMR) to document the refusal of shaving for female residents, unlike for male residents. The Director of Nursing acknowledged the lack of documentation for refusals and the understanding of the issue. Resident #23, who is dependent on staff for all activities of daily living due to conditions such as stroke and dementia, was observed resting in bed for an extended period. Despite the care plan indicating the need for repositioning and activity out of bed, the resident remained in bed until the surveyor's inquiry prompted action. The Director of Nursing was informed of the situation, and the resident was later observed sitting comfortably in a reclining wheelchair. These observations highlight the facility's failure to ensure proper documentation and execution of care plans for residents requiring assistance with daily living activities.
Failure to Implement Restorative Nursing Program for ROM
Penalty
Summary
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. Resident #36, who has severe vascular dementia and right-sided hemiplegia, was observed with a bent right arm and fist, indicating contractures. Despite being at high risk for contracture development, there was no care plan in place for Restorative Nursing or ROM exercises, and no splints or braces were observed in the resident's room. Resident #44, with a history of anoxic brain damage and impaired ROM in both upper and lower extremities, was found to have multiple splints and braces piled on top of their closet, which were rarely used. The resident reported that staff no longer assisted with ROM exercises, and there was no current order for Restorative Nursing or ROM. The resident's care plan included discontinued interventions for passive ROM and brace use, and there was no documentation of current ROM assessments or therapy evaluations. Interviews with facility staff, including the Director of Nursing (DON), revealed that the facility was in the process of developing a Restorative Nursing Program but had not yet implemented it. The DON confirmed the presence of contractures in both residents but could not provide explanations for the lack of Restorative Nursing services or specific ROM exercises. The facility did not provide a policy or procedure for Restorative Nursing by the conclusion of the survey.
Inadequate Staff Training and Equipment Monitoring Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staff training, equipment monitoring, and accident prevention, leading to a serious incident involving a resident. The resident, who was cognitively intact but required maximum assistance for daily activities, suffered a fractured tibia and fibula after sliding out of their wheelchair during transport in a facility van. The incident occurred because the seat belt securing the resident was not properly engaged, allowing the resident to fall and sustain injuries. The investigation revealed several deficiencies in the facility's procedures. The transport staff member, who had recently transitioned from a CNA role, did not receive adequate training or demonstrate competency in securing residents in the van. The seat belt in the van was faulty, as it clicked but did not securely latch, and this issue was not identified or addressed prior to the incident. Additionally, the facility did not conduct a thorough investigation or report the incident to the State Agency, and there was a lack of documentation regarding the training and competency of the transport staff. Interviews with the resident and staff highlighted discrepancies in the facility's account of the incident. The resident reported that their legs were caught under the chair during the fall, and they experienced significant pain and swelling upon returning to the facility. The facility's Administrator and DON were unable to provide consistent information about the incident, and there was no documentation of a comprehensive investigation or corrective actions taken to prevent future occurrences.
Deficiencies in Catheter Care and UTI Treatment
Penalty
Summary
The facility failed to ensure proper assessment, maintenance, and care of an indwelling urinary catheter for one resident and did not complete the treatment of a urinary tract infection (UTI) for another resident. For the resident with the indwelling urinary catheter, the catheter was observed to be maintained in an unsanitary manner, with the tubing soiled with a brown substance resembling bowel movement and not secured inside the securement device. The securement device itself was soiled and appeared old, indicating a lack of adherence to professional standards of practice for catheter care. Another resident experienced a delay and incomplete antibiotic therapy for a UTI. The resident was readmitted to the facility after a hospital discharge with a prescription for Cefpodoxime Proxetil to treat the UTI. However, the medication was not available upon the resident's return, and the first dose was not administered until two days later. The resident ultimately received only 17 out of the prescribed 18 doses. The facility's infection control audits revealed numerous and recurrent UTIs for this resident, yet there was no documentation of peri-care audits to ensure staff were performing perineal care correctly. The facility's Director of Nursing and Infection Control Nurse acknowledged the lack of documentation for peri-care audits and the delay in starting the prescribed antibiotic. The failure to secure the catheter properly and the delay in antibiotic administration highlight deficiencies in the facility's infection control practices and adherence to care protocols, potentially contributing to ongoing health issues for the residents involved.
Improper PICC Line Care and Documentation Issues
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Peripherally Inserted Central Catheter (PICC line), as evidenced by the lack of timely dressing changes and improper sterile technique during a dressing change. The resident, who was cognitively intact and required assistance with activities of daily living, had a PICC line dressing dated 5/24/24, despite facility policy and healthcare provider orders requiring weekly changes. The resident expressed concerns about the lack of care, indicating they had informed the nursing staff about the overdue dressing change, which was not addressed. During an observation, a Licensed Practical Nurse (LPN) failed to address the outdated PICC line dressing while attending to a beeping IV infusion. The Medication Administration Record (MAR) inaccurately documented a dressing change on 6/2/24, which was contradicted by the actual dressing date. Furthermore, during a dressing change observed by the Assistant Director of Nursing (ADON), sterile technique was compromised when the ADON turned their back on the sterile field, allowing for potential contamination. The Director of Nursing (DON) confirmed the discrepancy in the dressing change records and acknowledged the need for corrective action.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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