Belle Fountain Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverview, Michigan.
- Location
- 18591 Quarry Rd, Riverview, Michigan 48192
- CMS Provider Number
- 235376
- Inspections on file
- 29
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Belle Fountain Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an adequate emergency food supply, as observed during a survey. The Dietary Manager noted missing items such as chicken noodle soup, cheese sauce, and green beans from the designated emergency food area. The facility's policy requires maintaining sufficient food and supplies for emergencies, which was not adhered to.
The facility's kitchen had several food safety and sanitation deficiencies, including improper cleaning and drying of pans, failure to date-label food items, and storing milk cartons directly on the floor. Additionally, the air gap basin used for cleaning produce was inadequately cleaned, increasing the risk of foodborne illness.
A resident with hearing loss was not provided with a care plan to address their communication needs, despite being observed using writing materials to communicate. The Unit Manager was unaware of the need for communication aids, and the resident's medical record lacked interventions. The DON confirmed a care plan was created but resolved without reason, leaving staff without guidance. The MDS Nurse admitted to resolving the care plan without completion, impacting the resident's communication.
A resident with moderately impaired cognition and requiring assistance with ADLs was observed with unkempt personal hygiene, expressing a desire for grooming care that was not provided on scheduled shower days. The care plan indicated the need for assistance, which was confirmed by the Unit Manager and DON.
A resident with a Foley catheter was found with the catheter bag resting on the floor, contrary to the facility's care plan and policy. The resident, who required assistance with daily activities and had a neuromuscular dysfunction of the bladder, was observed in bed with the catheter bag improperly positioned. Staff interviews confirmed that a barrier should have been used to prevent the bag from touching the floor, highlighting a deficiency in catheter management.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, potentially affecting all residents. The Master Schedule for Nurses showed no 8-hour RN coverage on specific days, confirmed by the Director of Nursing (DON), who acknowledged staffing issues. The facility's staffing policy did not address the required RN coverage.
A resident was prescribed Seroquel without a specific diagnosis or valid informed consent. Despite declining psychiatric treatment, the resident was given the medication, and consent was improperly obtained from a family member who was not the DPOA. The facility's policy for psychotropic medication use was not followed.
The facility failed to develop or implement care plans for two residents receiving warfarin, despite physician orders to monitor anticoagulation therapy. Both residents lacked documented care plans for monitoring side effects or bleeding risks. The DON acknowledged the absence of care plans and the lack of a specific policy for anticoagulant use.
A facility failed to maintain accurate medical records for a resident on warfarin, resulting in incomplete documentation of INR results in the EHR. Despite physician orders to review the Warfarin Flowsheet nightly, only one entry was documented, and additional INR results were not included in the EHR. The DON acknowledged the oversight, and the physician confirmed that INR tests were conducted but not properly documented.
The facility failed to prevent expired food from being stored with active stock, risking foodborne illness for residents. Moldy hamburger and hot dog buns, along with undated or expired refrigerated items, were found during a kitchen inspection. Staff confirmed a resident was served moldy bread, violating the facility's food storage policy.
The facility failed to promptly respond to call lights for four residents, resulting in unmet healthcare needs. One resident waited over 15 minutes for bathroom assistance, another was left in a wheelchair for hours, and a third needed a bedpan urgently. A fourth resident reported waiting over two hours for assistance, leading to severe discomfort. The facility's policy required prompt response to call lights, but staff were busy, and a nurse turned off call lights before meeting residents' needs.
A resident with dementia and a history of falls was transferred to a hospital without proper documentation or communication of their medical needs. The facility's policy required a transfer form with specific information, which was not completed, leading to a deficiency.
The facility failed to conduct timely fall risk assessments for three residents, leading to falls without injury. Despite having policies requiring assessments within 24 hours of admission, these were not completed for residents with cognitive impairments and histories of falls. The DON confirmed the oversight, highlighting a deficiency in adhering to the facility's Fall Risk/Injury Prevention policy.
A resident with multiple diagnoses was repeatedly prescribed Ativan 0.5 mg every 12 hours PRN without proper documentation, behavioral monitoring, or physician evaluation. The resident reported difficulty receiving the medication and concerns about withdrawal symptoms. The facility failed to follow its policy on psychotropic medication use, including gradual dose reductions and non-pharmacological approaches.
Inadequate Emergency Food Supply
Penalty
Summary
The facility failed to ensure an adequate supply of emergency food was available, as observed during a survey. On March 10, 2025, an observation and interview with the Dietary Manager (DM) revealed that the emergency food supply was insufficient. A designated section in the dry food storage room was marked for emergency food, but upon comparison with the facility's emergency food supply list, it was found that chicken noodle soup, cheese sauce, and green beans were missing. The facility's policy, titled 'Disaster and Emergency Planning for Food Service,' dated February 3, 2023, mandates that adequate food, water, and disposable supplies be maintained to ensure meals can be prepared and served during emergencies. The Nursing Home Administrator acknowledged that the kitchen should audit the emergency food supply to ensure compliance.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the kitchen, as observed during a survey. Several deficiencies were noted, including the improper cleaning and drying of pans before stacking them with clean ones, and the failure to properly date-label food items. Specifically, opened containers of chicken and vegetable base were not labeled with expiration dates, and expired apple juice containers were found in the cooler. Additionally, a bag of hot dogs was labeled with an opened date but lacked an expiration date. In the dry food storage room, opened packages of spaghetti and polenta were not labeled with expiration dates. Further observations revealed that milk cartons were stored directly on the cooler floor, contrary to the requirement that they be stored at least 12 inches off the floor to prevent contamination. The air gap basin used for cleaning produce and thawing meat was found to be inadequately cleaned, with a build-up of residue and food debris. The Maintenance Director admitted to using bleach but not cleaning the basin, and the Dietary Manager acknowledged its dirty appearance. These practices increased the potential for foodborne illness among residents consuming food from the kitchen.
Failure to Implement Communication Care Plan for Hearing-Impaired Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a communication deficit for a resident with hearing loss. The resident, who was observed to be alert and using writing materials to communicate, expressed difficulty in hearing and interacting with others due to ineffective hearing aids. Despite the resident's clear communication needs, the Unit Manager was unaware of the necessity for communication aids, and the resident's medical record lacked any documented communication interventions. The Director of Nursing confirmed that a care plan for the resident's hearing deficit was created but was resolved without a reason, leaving no guidance for staff to provide appropriate care. The MDS Nurse admitted to resolving the care plan without completing it, acknowledging that this oversight negatively impacted the resident's ability to communicate. The absence of a care plan and corresponding Kardex for the CNAs hindered the resident's care and interaction with others.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADLs) care for a resident, identified as R23, who was observed on two occasions sitting in a wheelchair with facial hair, greasy unkempt hair, and long dirty untrimmed fingernails. During an interview, R23 expressed a desire to be shaved, have their hair washed and combed, and receive nail care, confirming that no assistance was offered for these tasks on scheduled shower days. R23, who has moderately impaired cognition and requires one-person assistance with all ADLs, was unable to recall the last time they received a shower or their scheduled shower days. The care plan, revised in February 2025, indicated that R23 required assistance with bathing, dressing, and personal hygiene due to muscle weakness. The Unit Manager confirmed that R23's scheduled shower days were Mondays and Thursdays, during which they should have received grooming care. The Director of Nursing stated that all residents should receive nail care and shaves if it is their preference.
Improper Catheter Bag Management
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, leading to a deficiency in catheter management. The resident, who was admitted with a neuromuscular dysfunction of the bladder and a history of repeated falls, was observed with a catheter bag resting on the floor. This observation was made while the resident was asleep in bed, which was positioned low to the ground. The facility's care plan for the resident included securing the catheter with a securement device and providing a barrier when the bed was in a low position. However, these interventions were not implemented, as evidenced by the catheter bag being wedged between the floor mat and the wheel of the bed. Interviews with the Unit Manager and the Director of Nursing revealed that the nurse aides were responsible for ensuring the catheter bags were properly hung and not on the floor. Both staff members acknowledged that a white basin should have been placed under the catheter bag to prevent it from touching the floor. The facility's policy on catheter care, dated August 2023, mandates appropriate care for residents with indwelling catheters, which was not adhered to in this instance. The failure to follow the care plan and facility policy potentially resulted in the risk of infection and dislodgement of the catheter.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which could potentially lead to inadequate coordination of emergency or routine care and unmet care needs for all residents. During the review of the Master Schedule for Nurses from January 1, 2025, to January 26, 2025, it was found that there was no consecutive 8-hour scheduled RN coverage on January 12, 19, and 25, 2025, with resident census numbers of 72, 77, and 71, respectively. The Director of Nursing (DON) confirmed the absence of RNs on these days and acknowledged the staffing issue, stating that RNs were recently hired to assist with coverage. Additionally, the facility's staffing policy, dated November 3, 2023, did not address the requirement for RN coverage for at least 8 consecutive hours a day, 7 days a week.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R506, had a specific diagnosis, clinical indications for use, or valid informed consent for the use of psychotropic medications. R506 was admitted with diagnoses including multiple falls, traumatic ischemia of muscle, and diabetes, and had a BIMS score indicating no cognitive impairment. Despite declining psychiatric treatment and services, R506 was prescribed Seroquel by Physician K without a corresponding diagnosis or clinical indication. The resident expressed a desire not to be on Seroquel, and the social worker informed the nurse and physician, but the medication was not discontinued. The facility's policy requires informed consent for psychotropic medications, which was not obtained from the appropriate authorized representative. A consent form was signed by a family member who was not the resident's DPOA, and the family member later clarified they had directed the social worker to contact another family member for consent. The resident was taken off Seroquel at the hospital, and the facility's policy for psychotropic medication use was acknowledged as not being followed by the Nursing Home Administrator.
Failure to Implement Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop or implement care plans for anticoagulant administration for two residents, R801 and R802, who were receiving warfarin. R801 was admitted with a history of pulmonary embolism and was prescribed warfarin 7.5 mg daily. Despite the physician's order to review the warfarin flowsheet every nightshift, there was no care plan or interventions documented for monitoring the side effects or risk of bleeding due to warfarin administration. The Director of Nursing (DON) acknowledged the absence of a care plan for R801 and confirmed that the facility lacked a specific policy for anticoagulant use. Similarly, R802, admitted with a history of Atrial Fibrillation, was prescribed warfarin 12.0 mg daily. The resident's care plan also lacked documentation for monitoring side effects or the risk of bleeding associated with anticoagulation therapy. The DON confirmed the absence of a care plan for R802 as well. The facility's Care Plan policy, last revised on 8/25/23, mandates a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, which was not adhered to in these cases.
Incomplete Documentation of INR Results for Resident on Warfarin
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R801, who was receiving warfarin for anticoagulation therapy. The deficiency was identified when the State Agency received a complaint regarding the monitoring of the resident's side effects from warfarin. The resident's Electronic Health Record (EHR) was found to be incomplete, with only one Warfarin Flowsheet documented, despite the physician's order to review the Warfarin Flowsheet every night shift. The missing documentation resulted in an unclear picture of the resident's blood clotting times and healthcare needs. The Director of Nursing (DON) acknowledged the incomplete documentation and produced two additional INR lab results that were not part of the resident's EHR. These results were obtained from the lab and were not documented in the facility's records. The facility's policy required that laboratory results be uploaded into the resident's EHR, but this was not done for R801. The physician confirmed that the INR blood tests were being conducted and reviewed through the lab, but the Warfarin Flowsheets were not up-to-date in the EHR.
Expired Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that expired food was not stored with active food stock, which could potentially lead to foodborne illness for all residents consuming food from the kitchen. During a kitchen tour, it was observed that several packs of hamburger and hot dog buns were opened, undated, and showed signs of mold. Additionally, other food items in the refrigerator, such as pre-made breakfast biscuits and sausages, were either undated or past their use-by dates. This oversight in food storage and labeling was confirmed by kitchen staff, who acknowledged the presence of mold on a sandwich served to a resident. The facility's Food Storage policy mandates that all food items be labeled and used within recommended time guidelines to prevent foodborne illness. However, the policy was not adhered to, as evidenced by the undated and expired food items found during the inspection. The Nursing Home Administrator was aware of the incident involving a resident being served moldy bread, indicating a lapse in monitoring and enforcing food safety protocols. This deficiency highlights a failure in the facility's food storage and labeling practices, posing a risk to resident health.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for four residents, leading to unmet healthcare needs. Observations on a specific date revealed that call lights for three residents remained on for an extended period, with one resident waiting over 15 minutes for assistance to go to the bathroom. Another resident had been waiting for hours to be assisted back to bed, and a third resident needed a bedpan urgently but was left waiting. The call lights were turned off by a nurse before the residents' needs were met, indicating a delay in response. Resident 810, who had chronic obstructive pulmonary disease and a history of falls, was observed waiting for assistance to use the bathroom. Resident 811, with Down's syndrome and a fracture, was left in a wheelchair for hours without being assisted back to bed. Resident 812, who had a fracture and required extensive assistance, was left waiting for a bedpan, risking incontinence. These residents had intact cognition, as indicated by their BIMS scores, and required varying levels of assistance for mobility. Resident 805 reported waiting over two hours for assistance on two occasions, leading to severe discomfort and the need to call emergency services. The facility's policy stated that staff should respond to call lights promptly and leave them on until the resident's needs were met. However, the nurse unit manager confirmed that the CNAs were busy, and she had to answer most call lights herself, turning them off before addressing the residents' needs.
Failure to Communicate Transfer Information to Hospital
Penalty
Summary
The facility failed to ensure proper communication of transfer information for a resident, identified as R802, to the receiving hospital. The resident, who had multiple diagnoses including dementia and a history of a fall with a fractured tibia, was admitted to the facility with severe cognitive impairment and required substantial assistance for mobility. On a specific date, the resident was found on the floor with a skin tear, prompting a physician to order a transfer to the hospital. However, there were no progress notes or transfer forms documenting the transfer, leaving the receiving hospital potentially unaware of the resident's medical needs and history. The Director of Nursing (DON) confirmed the absence of documentation regarding the transfer, acknowledging that the nurse should have completed a transfer form. The facility's policy on transfers and discharges, last revised in November 2023, outlines the necessary information to be included in a transfer form, such as contact information, advance directives, resident status, diagnoses, allergies, and special care instructions. The lack of adherence to this policy resulted in a deficiency, as the required information was not communicated to the hospital, potentially impacting the resident's care.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to implement fall interventions for three residents, resulting in a deficiency related to fall risk assessments. Resident 802, who had severe cognitive impairment and a history of falls, was admitted without a fall risk assessment. This resident experienced two falls, one resulting in a skin tear and another in a laceration, before being sent to the hospital. Similarly, Resident 807, with intact cognition and a history of joint replacement surgery, and Resident 809, with moderately impaired cognition and a history of a lumbar fracture, were also admitted without fall risk assessments. Both residents experienced falls without injury. The Director of Nursing confirmed that no fall risk assessments were conducted within 24 hours of admission or prior to the falls for these residents. The facility's Fall Risk/Injury Prevention policy mandates that a fall risk assessment be completed within 24 hours of admission, quarterly, or when a significant change in condition occurs. The policy also states that a score of greater than 10 on the assessment indicates an increased risk of falls, and the interdisciplinary team may add interventions for residents deemed at risk. The lack of timely fall risk assessments for these residents represents a failure to adhere to the facility's policy, contributing to the deficiency.
Failure to Provide Rationale and Monitoring for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide rationale, behavioral monitoring, or a physician evaluation for the extended use of a PRN psychotropic medication for a resident. The resident, who had multiple diagnoses including Sepsis, Depression, Anxiety, and Adjustment Disorder, was prescribed Ativan 0.5 mg every 12 hours PRN for 14 days, which was repeatedly re-ordered without proper documentation or evaluation. The resident reported difficulty in receiving the medication and expressed concerns about withdrawal symptoms due to her long-term use of Ativan at home. There was no evidence of psychiatric services being offered or accepted, and no documentation of discussions regarding the risks and benefits of the medication use was found in the resident's EHR. The care plan for the use of psychotropic medications was initiated 15 days after the initial prescription of Ativan, but it lacked proper follow-up and documentation. The interventions included consulting with pharmacy, considering dosage reduction, and reviewing behaviors and alternate therapies, but there were no records of these actions being taken. The resident's physician continued prescribing the medication based on the resident's requests without documented discussions about alternative treatments or non-pharmaceutical interventions. Additionally, there was no AIMS assessment or behavior monitoring documented in the resident's EHR. The Director of Nursing confirmed the lack of psychiatric services and the responsibility of social work and the resident's physician in managing the psychotropic medication. The social worker admitted to not following up with the resident due to the absence of reported concerns from nursing staff. The physician acknowledged the continued prescription of Ativan without considering alternative treatments or a gradual dose reduction. The facility's policy on psychotropic medication use emphasized the need for gradual dose reductions, non-pharmacological approaches, and proper documentation, which were not adhered to in this case.
Latest citations in Michigan
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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