Cascade Senior Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Michigan.
- Location
- 2121 Robinson Road, Jackson, Michigan 49203
- CMS Provider Number
- 235574
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cascade Senior Care Center during CMS and state inspections, most recent first.
A resident admitted with malnutrition, postprocedural complications, digestive system disorders, and an abdominal surgical wound, and who was cognitively intact per MDS, did not receive assistance with showers or bed baths for 11 days after admission. A family member reported the resident did not receive showers and was often found soiled with urine and not cleaned up for the day. Facility shower logs confirmed no bathing occurred during this period, and progress notes showed no documented refusals. The DON stated that residents are expected to receive showers twice weekly and that refusals are to be documented in the EMR, but could not explain the lack of bathing for this dependent, post-surgical resident.
A resident with intact cognition and multiple medical conditions, including malnutrition and postprocedural digestive complications, sustained bilateral calf skin tears during a transfer back to bed. The resident reported her legs were pushed against the bedframe, causing pinching and pain, and bleeding was later observed. Documentation showed the resident was non-ambulatory and required 2PA for transfers with an EZ stand, but interviews revealed that only one CNA performed the transfer and that the second staff member present was not assisting. There were conflicting accounts about whether a mechanical lift was used, and the injury was believed to have occurred when loose skin was pinched between the bedframe and transfer equipment.
The facility failed to ensure staff consistently used required PPE for Contact precautions. A resident on Contact precautions for diarrhea, with moderately impaired cognition and diagnoses including malnutrition and Type 2 DM, had a Contact precautions sign posted, yet CNAs repeatedly entered and exited the room wearing only surgical masks and without gowns or gloves, despite acknowledging that gowns and gloves were required. A PPE cart near the room lacked gloves, and the resident reported staff did not wear gowns and usually only wore gloves. A laundry aide was also observed entering multiple rooms, including a Contact precautions room, without hand hygiene and without donning additional PPE. These practices were inconsistent with the facility’s policy and stated expectations that staff wear gowns and gloves and don PPE upon room entry and discard it before exiting.
The facility did not follow required procedures for timely reporting of an alleged abuse incident involving two cognitively impaired residents. After one resident accused a staff member of attempted rape during care, the incident was not reported to the State Agency within the mandated two-hour timeframe, despite facility policy requiring immediate reporting.
Two residents with end-stage renal disease did not receive proper medication management, accurate documentation, or adherence to physician orders regarding dialysis schedules and weight monitoring. One resident missed multiple doses of a prescribed medication, had altered dialysis days without physician notification, and experienced significant weight loss without intervention or dietician oversight. Another resident missed a dialysis session due to missing equipment, with no documentation or physician notification. Required assessments and communication forms were also missing.
Two residents requiring dialysis did not have proper documentation of dialysis communication, physician notification, or weights when their dialysis schedules were altered or missed. One resident was not sent with required equipment, resulting in an incomplete dialysis session, and staff could not explain or justify changes to the dialysis schedule.
A resident with end-stage renal disease and hyperphosphatemia did not receive any doses of a prescribed medication, Sevelamer HCl, because it was not available in the facility. Despite this, the MAR inaccurately indicated that some doses were administered. The DON confirmed the medication was never in-house, and the family was only informed after several days. The resident was later transferred to a hospital due to a change in condition.
A deficiency was cited for failing to address certain general requirements under LSC Sections 18.1 and 19.1 that were not covered by the existing K-tags. The report does not specify the exact actions or omissions involved.
A resident with a history of respiratory failure and other chronic conditions was admitted from the hospital with ongoing hypoxia and required respiratory support. After reporting difficulty breathing and requesting a change from CPAP to oxygen via nasal cannula, the resident was not assessed by a licensed nurse, and as-needed inhaled medications were not administered. The resident was later found unresponsive and pronounced deceased, with staff interviews confirming a lack of follow-up assessment after the report of respiratory distress.
The facility did not consistently respond to resident call lights in a timely manner, with multiple residents experiencing wait times ranging from 15 minutes to two hours for assistance with personal care and toileting. Documentation and resident interviews confirmed repeated delays, particularly during shift changes, and some residents reported episodes of incontinence as a result.
The facility did not provide timely and accurate NOMNC and SNF ABN forms to two residents, with both notices being signed either one day before or on the last covered day, rather than within the required advance notice period. The social worker responsible for issuing these notices was unable to explain the delay or inaccuracy.
A resident with multiple medical and cognitive conditions did not have a comprehensive care plan addressing activity preferences, resulting in boredom and lack of awareness of available activities. The resident's records lacked documentation of activity preferences, and staff interviews confirmed that expected practices for care planning and activity calendar distribution were not followed.
A resident with moderate cognitive impairment and multiple medical conditions was not provided with meaningful, individualized activities. The resident reported boredom, was unaware of any activity calendar, and had not been invited to participate in activities. Review of records showed no care plan for activity preferences and only solitary activities documented, with no evidence of group activities being offered.
Two residents were found with medications at their bedside without required assessments, physician orders, or care plans for self-administration, and an opened multi-dose vial in the medication room refrigerator was not dated as required. Staff confirmed these practices did not follow professional standards for medication storage and labeling.
A facility failed to develop a comprehensive care plan for a resident with a baclofen pump. The resident's medical records lacked documentation of the pump, and staff were unaware of its presence until informed by the resident's wife. The care plan intervention for the pump was discontinued, leading to inadequate care planning for the resident's needs.
A resident with a baclofen pump was not properly monitored due to a lack of documentation and awareness among staff. The facility failed to ensure coordination of care, as the pump's presence and management were not included in the resident's medical record or care plan. Staff interviews revealed they were unaware of the pump until informed by the resident's family, leading to a deficiency in care.
The facility failed to maintain food service equipment and properly date and store food products, affecting 55 residents. Observations included loose temperature gauges on the dish machine, soiled flooring, and undated food items in refrigerators. These conditions indicate non-compliance with the 2017 FDA Model Food Code and the facility's sanitation policy.
The facility failed to maintain a clean and safe environment, affecting 55 residents. Observations included worn and damaged furniture, soiled surfaces, heavily stained carpeting, non-functional light assemblies, and missing tiles. Record reviews indicated that existing cleaning and maintenance policies were not effectively implemented.
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. One resident had conflicting documentation regarding their code status, and the facility could not provide documentation to support their incapacity. Another resident had their spouse designated as their responsible party without documentation to support their incapacity.
The facility failed to ensure accurate MDS coding for two residents. One resident's discharge was incorrectly coded as a hospital discharge instead of home, and another resident's MDS inaccurately reflected antidepressant use despite no prescription. The errors were confirmed by the MDS Coordinator.
Failure to Provide Timely Bathing and Hygiene Assistance for Dependent Post-Surgical Resident
Penalty
Summary
The facility failed to provide required assistance with activities of daily living (ADLs), specifically bathing and hygiene, for one dependent resident. The resident was admitted with diagnoses including malnutrition, postprocedural complications, and digestive system disorders, and had an abdominal surgical wound. An MDS assessment showed the resident had intact cognition with a Brief Interview for Mental Status score of 13/15. According to a family member interviewed by phone, the resident did not receive assistance with showers while in the facility and was often found soiled with urine and not cleaned up for the day. Review of the facility’s shower logs showed the resident did not receive a shower or bed bath until 11 days after admission, and review of progress notes revealed no documented refusals of bathing during that period. In an interview, the DON stated the facility’s expectation is that residents receive showers twice a week and that refusals are documented in the electronic medical record, but could not provide an explanation for the lack of showers for this post-surgical resident during the first 11 days after admission.
Failure to Provide Required Two-Person Assist During Transfer Resulting in Skin Tears
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in skin tears to both calves during a transfer back to bed. The resident had been admitted with diagnoses including malnutrition and postprocedural complications of the digestive system and had an abdominal surgical wound. An MDS assessment showed intact cognition. On the date of the incident, the resident reported feeling the backs of her legs pushing against the bedframe while being put back into bed and then feeling pinching, pain, and wetness under her legs, after which bleeding and skin tears were noted on the lateral aspects of both calves. The incident report identified that a mechanical lift (EZ stand) was in use during the transfer and that the resident experienced mild pain in her lower legs after being transferred to the bathroom and back. Interviews and record review revealed discrepancies and failures related to required transfer assistance. The DON reported that the resident required two-person assistance for transfers with an EZ stand and that a second staff member present in the room at the time of the incident was not assisting with the transfer but gathering supplies. The DON stated it was believed the resident’s loose skin was pinched between the bed frame and the EZ stand. In contrast, CNA F reported transferring the resident by herself, having the resident pivot from the wheelchair back to the bed, and stated that an EZ stand was not used and that she believed the resident was a one-person assist at the time. The resident’s care plan documented the resident as non-ambulatory with transfers requiring two-person assistance using a wheeled walker, and physician orders in effect at the time specified transfers with two-person assistance using an EZ stand.
Failure to Use Required PPE for Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement its infection prevention and control program by not ensuring required PPE use for residents on Contact precautions. A resident admitted with diagnoses including malnutrition and Type 2 Diabetes Mellitus, and with moderately impaired cognition per a recent MDS, had physician orders for Contact transmission-based precautions for diarrhea. On multiple observations, CNAs entered and exited this resident’s room, which had a Contact precautions sign posted on the door, wearing only surgical masks and without donning gowns and gloves. One CNA acknowledged that Contact precautions required a gown and gloves and confirmed that neither she nor another CNA had donned the required PPE. The resident reported that staff did not wear gowns when entering the room and normally only wore gloves. A PPE cart near the resident’s room was observed to be missing gloves, and staff had to retrieve gloves from another resident’s room. Additional observations showed that a laundry aide entered four resident rooms without performing hand hygiene and wearing only a surgical mask, and then entered a room with a Contact precautions sign without donning any additional PPE. The laundry aide stated that she normally just went in and out with clean laundry without using a gown or gloves. The Corporate Infection Control staff member reported that the facility’s expectation was that all staff entering a Contact precautions room don a gown and gloves. The facility’s written Transmission-Based Precautions policy stated that healthcare personnel caring for residents on Contact precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, and that PPE is to be donned upon room entry and discarded before exiting to contain pathogens.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Two residents with cognitive impairments, one with Alzheimer's disease and severe impairment and another with unspecified dementia and moderate impairment, were involved in an incident where one resident was observed grabbing the other's foot. During care, the resident accused a staff member of attempted rape, prompting immediate cessation of care. Both residents were assessed and found to have no injuries. Law enforcement responded but could not obtain statements due to the residents' inability to recall the event. The incident occurred at 11:00 AM and was discovered at 12:30 PM, but was not reported to the State Agency until 5:02 PM, exceeding the required two-hour reporting window. The Nursing Home Administrator confirmed that abuse allegations must be reported immediately, but this protocol was not followed in this case.
Failure in Medication Management, Documentation, and Adherence to Physician Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper medication management, accurate documentation, recognition of changes in condition, and adherence to physician orders for two residents with end-stage renal disease dependent on dialysis. For one resident, there was an active physician order for transport to dialysis on specific days and notification of the physician for missed appointments, as well as weight monitoring. The resident's dialysis schedule was altered without justification or documentation, and there was no evidence of physician notification or weight documentation for missed or changed dialysis sessions. Additionally, the resident did not receive the prescribed Sevelamer HCl for chronic kidney disease, with multiple doses marked as administered on the MAR despite the medication not being available in-house. Nurses' notes indicated the medication was not available, and the DON confirmed the MAR entries were inaccurate and that the medication was never present during the resident's admission. The same resident experienced poor oral intake, with documentation showing less than 75% meal consumption at every meal and no evidence that snacks or alternatives were offered. There was only one recorded weight during the admission, reflecting a significant weight loss, with no documentation addressing the cause or interventions. The resident did not receive a Registered Dietician consultation or progress notes, and required social services assessments were not completed until after discharge. The social worker reported being unable to complete assessments due to the resident's lethargy but did not notify nursing staff, and there was no documentation of assessment attempts. Family members reported concerns about the resident's eating difficulties and mood changes, which were not addressed by the facility. For the second resident, there was also a failure to adhere to the prescribed dialysis schedule and to notify the physician or document weights when dialysis was missed or altered. The resident missed a dialysis session due to the facility not sending the required Hoyer sling, and there was no documentation of physician notification or weight monitoring. Dialysis communication forms were missing from the medical record, and staff could not explain the changes to the dialysis schedule. These deficiencies demonstrate a lack of compliance with physician orders, medication management, documentation, and recognition of changes in condition for residents requiring complex care.
Failure to Maintain Dialysis Coordination and Documentation
Penalty
Summary
The facility failed to maintain required dialysis coordination and communication documentation for two residents who required dialysis services. Both residents had physician orders specifying dialysis schedules and instructions to notify the physician of missed appointments and to obtain weights. However, the medical records for both residents lacked dialysis communication forms, documentation of physician notification, and records of weights when dialysis appointments were missed or altered. Staff were unable to explain or justify changes to the dialysis schedules, and there was no documentation to support why the residents' dialysis days were changed from the ordered schedule, despite the dialysis center being open on the originally scheduled days. One resident was not sent with the necessary Hoyer sling for transfer at the dialysis center, resulting in an incomplete dialysis session, and there was no documentation that the physician was notified or that a weight was obtained. The other resident's dialysis days were altered without explanation or documentation, and again, there was no evidence of physician notification or weight documentation. The Director of Nursing acknowledged that dialysis communication forms could not be located and that the facility was working to improve the process.
Failure to Accurately Document and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure accurate documentation and proper maintenance of medical records for a resident admitted with end-stage renal disease dependent on dialysis and a disorder of phosphorus metabolism. The resident was prescribed Sevelamer HCl, an oral medication to manage hyperphosphatemia, to be administered three times daily with meals. Review of the Medication Administration Record (MAR) showed multiple instances where doses were marked as "OS" (see nurses' note) or as administered, but corresponding nurses' notes indicated the medication was not available. The MAR inaccurately reflected that some doses were given when, in fact, the medication was never present in the facility during the resident's stay. Interviews with the family member and the Director of Nursing (DON) confirmed that the resident did not receive any doses of Sevelamer from admission until discharge, as the medication could not be obtained from the pharmacy. The DON verified that the medication was not in the facility at any time and acknowledged that the MAR entries indicating administration were not accurate. The family was notified of the issue only after several days, and the resident was eventually transferred to a hospital due to a change in condition. The inaccurate documentation and failure to provide the ordered medication constituted a deficiency in maintaining accurate and complete medical records.
Unaddressed General Life Safety Code Requirements
Penalty
Summary
A deficiency was identified regarding general requirements under Life Safety Code (LSC) Sections 18.1 and 19.1 that were not addressed by the provided K-tags. The report notes that there are unmet general requirements, but does not specify the exact actions or omissions that led to the deficiency. No specific details about residents, staff, or events are provided in the report.
Failure to Assess and Monitor Respiratory Status Following Resident Distress
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with a history of respiratory failure, COPD, obstructive sleep apnea, type 2 diabetes, and heart failure. Upon admission from the hospital, the resident arrived hypoxic, requiring high-flow oxygen and BiPAP, with persistent low oxygen saturation and increased work of breathing. Despite these critical symptoms, there was no documentation of a comprehensive respiratory assessment or clear orders for the use of CPAP or BiPAP in the medical record, and the admission assessment did not indicate the use of these devices. On the morning of the incident, the resident requested removal of their CPAP and assistance with oxygen via nasal cannula, reporting difficulty breathing. A CNA assisted with this request and reported the resident's oxygen saturation as 90-91%. However, there was no evidence that a licensed nurse performed a follow-up assessment after the resident reported respiratory distress. The resident was later found unresponsive, with signs of lividity and rigor mortis, and was pronounced deceased. The medical record also showed that as-needed inhaled medications for shortness of breath were not administered or documented as given. Interviews with staff revealed uncertainty regarding the oxygen flow rate and a lack of clarity about the resident's respiratory status prior to being found unresponsive. The facility's Regional Clinical Director acknowledged that a follow-up nursing assessment should have occurred after the resident reported difficulty breathing. The failure to assess and monitor the resident's respiratory status after a report of distress directly contributed to the deficiency.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for five residents, as evidenced by direct observations, resident interviews, and review of call light response time reports. Residents with moderate cognitive impairment, diabetes, heart failure, peripheral vascular disease, and end stage renal disease reported waiting between 15 minutes to as long as two hours for staff assistance after activating their call lights. These delays occurred across multiple shifts, with some residents specifically noting longer wait times during shift changes. Call light response reports confirmed that call lights remained on for over 20 minutes on numerous occasions, with the longest single wait times ranging from 33 to 39 minutes for individual residents. Residents described waiting extended periods for assistance with toileting, transfers, and other personal care needs, sometimes resulting in episodes of incontinence. The facility's own records corroborated these reports, showing repeated instances where call lights were not answered within the facility's stated goal of 10 minutes. The Nursing Home Administrator acknowledged awareness of the issue and ongoing complaints regarding delayed response times.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and accurate Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents. For one resident, the NOMNC indicated the last covered day under Medicare A would be 4/16/25, but the notice was signed only one day prior, on 4/15/25, not meeting the required advance notice period. The corresponding SNF ABN was also signed on 4/15/25, stating that private billing would begin on 4/18/25. For another resident, the NOMNC showed the last covered day as 2/19/25, but the form was signed and dated on the same day, again failing to provide the required notice period. During an interview, the social worker responsible for issuing these notices confirmed her responsibility and usual practice of providing three days' notice, but could not explain why the notices for these two residents were issued late and inaccurately.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the activity preferences and needs of a resident with multiple complex medical diagnoses, including neurocognitive disorder, depression, and chronic pain. The resident, who had moderate cognitive impairment, reported feeling bored and was unaware of any activity calendar or invitations to participate in facility activities. Observations confirmed that no activity calendar was posted in the resident's room during initial visits, and the medical record lacked documentation of a care plan for activity preferences, despite the Life Enrichment Assessment indicating that functional status related to activities should be addressed in the care plan. Interviews with facility staff, including the Nursing Home Administrator and Activity Assistant, revealed that it was expected for all residents to have documented activity preferences in their care plans and to receive an activity calendar. However, the resident's records did not reflect these practices, and activity participation documentation showed mostly solitary activities, with limited staff involvement and no evidence of group activities being offered. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure a comprehensive, individualized care plan for the resident's activity needs.
Failure to Provide Individualized Activities and Activity Planning
Penalty
Summary
The facility failed to provide meaningful, individualized activities for one resident with multiple complex medical conditions, including Lewy Body Dementia, depression, and schizoaffective disorder. The resident was observed multiple times sitting alone in her room and expressed feeling bored. She reported not being aware of any activity calendar or being invited to participate in facility activities. No activity calendar was observed in her room during initial observations, and her medical record did not include a care plan outlining her activity preferences or interests. The Life Enrichment Assessment indicated a need to address functional status in the care plan, but this was not reflected in her records. Documentation of the resident's activity participation over the past 30 days showed only solitary activities, such as conversation/reminiscing, with several instances occurring without staff involvement. There was no evidence of group activities being offered. Interviews with facility staff confirmed that it was expected for all residents to receive an activity calendar and have their activity preferences included in their care plan, but this was not done for this resident. The deficiency was identified through observations, interviews, and record reviews, which demonstrated a lack of individualized activity programming and failure to follow facility expectations for activity provision and documentation.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents. One resident was observed with a Trelegy inhaler and Azelastine nasal solution at her bedside and reported self-administering these medications without nurse supervision. There was no physician order, self-administration assessment, or care plan in place for this resident to self-administer medication. Another resident was found with a dulera inhaler and fluticasone nasal spray on her bedside table, which had been left by a nurse without being administered. This resident stated she does not self-administer medication, and there was no assessment, physician order, or care plan for self-administration in her record. Additionally, during a review of the medication storage room, an opened multi-dose vial of tuberculin was found in the refrigerator without a date indicating when it was opened. Staff interviews confirmed that it is professional practice to date multi-dose vials upon opening, and the LPN acknowledged the vial should have been dated and would be disposed of. These findings demonstrate failures in medication storage, labeling, and adherence to professional standards for medication management.
Failure to Implement Comprehensive Care Plan for Resident with Baclofen Pump
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a baclofen pump. The resident was admitted with diagnoses including dementia and a baclofen pump, which was not properly documented in the care plan. The medical records from the physician's office managing the baclofen pump indicated a scheduled decrease in dosage and a plan for oral baclofen administration, but this information was not included in the resident's medical record at the facility. Consequently, there were no orders or care plans indicating the presence of the baclofen pump until shortly before the resident's death. Interviews with facility staff, including LPNs, the Clinical Care Coordinator, and the Director of Nursing, revealed a lack of awareness about the resident's baclofen pump until it was mentioned by the resident's wife. The staff reported that if a resident had a baclofen pump, it should have been included in the care plan. The facility's documentation showed that the baclofen pump was last filled on a specific date, but the care plan intervention for the pump was discontinued, leading staff to believe it was no longer in use. This oversight resulted in a failure to provide appropriate care planning for the resident's medical needs.
Failure to Monitor Baclofen Pump in Resident
Penalty
Summary
The facility failed to ensure proper coordination of care and monitoring for a resident with a baclofen pump, an implanted device that delivers muscle relaxant medication directly into the spinal fluid. The resident, who had diagnoses including dementia and muscle contracture, was admitted with a baclofen pump that was not adequately documented or monitored. The family reported that the pump was due to run out of medication, but the facility had no records or care plans indicating the presence of the pump or the need for monitoring for baclofen withdrawal. Interviews with staff revealed a lack of awareness about the resident's baclofen pump. Several Licensed Practical Nurses (LPNs), the Clinical Care Coordinator (CCC), and the Director of Nursing (DON) were unaware of the pump until informed by the resident's family. The facility's documentation showed that the baclofen pump was last filled several months prior, and there was no subsequent documentation or care planning for the pump's management or the resident's potential withdrawal symptoms. The facility's failure to document and monitor the baclofen pump led to a lack of appropriate care for the resident. The resident's medical record did not include necessary orders or care plans for the baclofen pump, and there was no monitoring for withdrawal symptoms after the pump was empty. This oversight resulted in a deficiency in the coordination of care for the resident, as the staff was not informed or prepared to manage the resident's condition effectively.
Deficiencies in Food Service Equipment Maintenance and Food Storage
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, date mark all potentially hazardous ready-to-eat food products, and properly date, label, and store food products, affecting 55 residents. During a comprehensive tour of the food service area, several deficiencies were noted, including loose and fogged temperature gauges on the mechanical dish machine, soiled flooring surfaces in the Dietary Manager's office and walk-in cooler, and an improperly mounted garbage disposal spray arm valve assembly. Additionally, the can opener mounting bracket and the door gaskets of the True 2-door reach-in cooler were observed with accumulated food residue and dirt deposits. Further observations revealed that the reach-in refrigerator contained uncovered frozen vegetables, expired grapes, and an opened half-gallon of whole milk without a date. The walk-in refrigerator also contained an undated container of pasta salad. These findings indicate a failure to adhere to the 2017 FDA Model Food Code, which requires proper maintenance of equipment, cleanliness of food-contact surfaces, and appropriate date marking of potentially hazardous ready-to-eat food products. The facility's policy on sanitation inspection, dated 08-11-2022, was reviewed and found to be in non-compliance with state and federal regulations. The policy mandates that all food service areas be kept clean, sanitary, and free from litter and rubbish. However, the observed conditions, including soiled equipment and improper food storage practices, demonstrate a significant lapse in maintaining the required standards of cleanliness and food safety, thereby increasing the potential for cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 55 residents. During an environmental tour, several deficiencies were noted, including worn and damaged furniture, soiled and encrusted surfaces, and heavily stained and soiled carpeting. Specific areas of concern included the nurses' stations, beauty shop, rehabilitation unit, memory care unit, dining rooms, janitor closets, and activity rooms. Additionally, non-functional light assemblies and missing tiles were observed, indicating a lack of proper maintenance and cleaning routines. Record reviews revealed that the facility had policies in place for routine cleaning and disinfection, as well as environmental services inspections. However, the observations made during the tour indicated that these policies were not being effectively implemented. The deficiencies noted increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality, posing a risk to the health and safety of the residents, staff, and the public.
Failure to Honor Resident's Code Status and Decision-Making Rights
Penalty
Summary
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. Resident #37, who was cognitively intact with a BIMS score of 13 out of 15, had conflicting documentation in their medical record regarding their code status. Despite having a DNR document signed by the resident, the Director of Nursing (DON) reported that the resident was not their own responsible party and that the DNR was invalid. However, there was no documentation provided to support that Resident #37 had been deemed incompetent to make their own medical decisions. Additionally, the resident's OBRA Level II Evaluation indicated that they acted as their own person for medical and daily choices, although they had a conservator for financial decisions due to a traumatic brain injury. The facility failed to provide documentation to the survey team that supported the resident's incapacity to make medical decisions before the survey exit date. Furthermore, the DON reported that the resident had expressed a desire to be a full code status upon returning from the hospital, contradicting the previously signed DNR document. This inconsistency in honoring the resident's code status wishes was a significant deficiency in the facility's care practices. Resident #3, who had severe cognitive impairment with a BIMS score of 5 out of 15, had their spouse designated as their responsible party. However, there was no documentation to support that Resident #3 had been deemed incompetent to make their own medical decisions. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both reported that the resident's spouse was making medical decisions on their behalf, but they were unable to provide any capacity determination documentation. This lack of documentation to support the resident's incapacity to make their own medical decisions was another significant deficiency in the facility's care practices.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for two residents. Resident #54 was admitted to the facility and later discharged home, but the Discharge MDS incorrectly indicated that the resident was discharged to the hospital. This error was confirmed by the MDS Coordinator during an interview. Resident #37, who had diagnoses including diabetes, depression, and schizophrenia, was found to have an error in the quarterly MDS. The MDS incorrectly reflected the use of an antidepressant, although the resident had not been prescribed any antidepressant since admission. The MDS Coordinator acknowledged the coding error, attributing it to a possible misclassification of an antipsychotic medication as an antidepressant.
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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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