Chesaning Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesaning, Michigan.
- Location
- 201 South Front Street, Chesaning, Michigan 48616
- CMS Provider Number
- 235641
- Inspections on file
- 21
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Chesaning Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found persistent strong urine and body odors, uncovered urinals left near drinking cups, cluttered rooms, and improper storage of medical equipment in both resident rooms and the therapy area. The therapy room was used for excess equipment storage, obstructing therapy activities, and had a non-functioning air conditioner. Staff and family reported ongoing cleanliness issues, and infection control practices were not consistently followed.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
Two residents with feeding tubes did not receive proper care due to missing or unclear physician orders, lack of documentation of tube feedings and water flushes, and incomplete care plans. Nursing staff were unaware of or did not follow orders for tube maintenance, resulting in inconsistent care and, in one case, severe abdominal pain requiring hospital transfer.
A resident with a Mediport for chemotherapy did not have physician orders, documentation, or care plan interventions addressing the central line. Facility nurses were not monitoring the site for complications, and the only policy available addressed flushing and removal, not ongoing management.
A resident with chronic kidney disease and a dialysis fistula did not have physician's orders or care plans addressing dialysis services or access site monitoring. Facility staff failed to complete required pre- and post-dialysis assessments and left most dialysis communication forms incomplete, contrary to facility policy.
A long-term care facility failed to implement effective COVID-19 preventive measures during an outbreak, resulting in 11 residents and 10 staff members testing positive. The facility did not fit-test staff for N95 masks, used expired test kits, and failed to isolate COVID-positive residents properly. Staff were observed wearing only surgical masks, and there was inadequate education on preventive measures. Resident #7, with multiple health conditions, was hospitalized with COVID-19. The facility's lack of adherence to its policies and CDC guidelines contributed to the outbreak.
The facility failed to update the Resident Roster Matrix (CMS-802) to reflect COVID-positive residents during an outbreak. Despite isolation signs, residents were observed in communal areas. An LPN confirmed the oversight, leading to potential unmet care needs.
The facility failed to update care plans for several residents, leading to unmet care needs. A resident with a UTI and Covid was hospitalized without proper care plan interventions. Another resident with severe cognitive impairment lacked monitoring for infection signs. Two residents experienced significant weight changes without care plan updates. These deficiencies show a lack of comprehensive and current care plans.
The facility failed to prevent and manage urinary tract infections for several residents, leading to potential health risks. A resident was hospitalized with multiple infections, including a UTI, after completing antibiotic treatment. Another resident received antibiotics before a urine culture, which later showed no specific organism, and did not meet infection surveillance criteria. Multiple antibiotics were administered to another resident without meeting criteria or identifying organisms. Staff education on perineal and catheter care was outdated.
The facility failed to maintain clean and properly stored medication carts, with crushed pills and dust found in drawers. Staff were unclear about cleaning responsibilities. Unlocked treatment carts contained undated medications, and insulin lacked open dates. Medication administration errors included unidentified meds in a cart and incorrect documentation of a declined nasal spray.
The facility failed to maintain sanitary conditions and proper food safety practices in the kitchen, affecting 35 residents. Issues included a malfunctioning hand washing sink, dirty equipment, and undated food items. Staff interviews revealed a lack of oversight due to the Dietary Manager's absence and ongoing cleanliness concerns noted by the Dietitian.
The facility did not analyze monthly infection data for July and August, missing critical analysis of infection rates and related factors. Additionally, during wound care for a resident with a chronic wound, staff failed to use enhanced barrier precautions, despite signage indicating the need for such measures. This oversight increased the risk of cross-contamination and infection spread.
The facility failed to monitor and justify antibiotic use for four residents, leading to inappropriate administration and potential health risks. A resident experienced recurrent UTIs and was given antibiotics without organism identification. Another resident with severe cognitive impairment received antibiotics despite not meeting infection criteria. Multiple antibiotics were administered to a third resident without proper culture or organism identification. A fourth resident was treated for UTIs despite urine cultures showing mixed flora. The facility lacked adherence to infection criteria and did not provide ongoing staff education on care practices.
A diabetic resident experienced a change in condition with stomach pain and was on antibiotics for a UTI. Despite completing the antibiotic therapy, the resident's condition worsened, leading to hospitalization where she was diagnosed with COVID-19 and a UTI, with low sodium and critically low glucose levels. The facility failed to monitor or document glucose levels during this acute change, delaying treatment for low blood glucose.
The facility failed to ensure timely weight monitoring for two residents, leading to a lack of follow-up on significant weight changes. One resident experienced weight fluctuations without updates to their care plan, while another had inconsistent weight recordings with no triggered changes in the electronic medical record. Staff interviews revealed inconsistencies in weight measurement methods and a lack of timely re-weighing, contributing to the deficiency.
A facility failed to document and monitor a resident's behavioral health care, leading to a deficiency. The resident, with multiple mental health diagnoses, had an undated care plan noting attention-seeking behaviors. However, there was no evidence of monitoring or documentation of interventions in the resident's records. Interviews revealed a lack of a behavioral program and policy, and staff were not trained on the provided behavioral policy.
A resident was administered Abilify, Trazadone, and Ativan without obtaining the necessary consents from the responsible party. The facility's policy requires education on risks and benefits of psychotropic drugs, but this was not followed. The social worker's attempts to obtain consent were unsuccessful due to incorrect email addresses, leaving the consents unsigned.
The facility failed to ensure a clean and safe environment, with issues such as extreme odors, stained curtains, and dirty fans observed in resident rooms. Hazards like missing wood and bent heater edges were noted, along with unsanitary conditions like uncovered toothbrushes and urinals with urine. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness, and the facility's policy on environmental quality was not followed.
A cognitively impaired resident, requiring assistance with all ADLs, did not receive the scheduled showers as per the facility's policy, despite adequate staffing. The resident, with a history of stroke, seizures, and Alzheimer's, only received two showers and refused one, with no documented follow-up. This failure increased the likelihood of negative outcomes such as offensive odors and skin issues.
Environmental Cleanliness and Safety Deficiencies in Resident and Therapy Areas
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment in both resident rooms and the therapy area. Observations included persistent strong urine and body odors in several rooms and hallways, urinals left half-full and uncovered on nightstands or floors near drinking cups, and cluttered rooms with personal items and medical equipment improperly stored. In one instance, a resident's breakfast tray with perishable food remained untouched for approximately four hours, and urinals were left on the floor. Additionally, oxygen tubing and nasal cannulas were not stored in protective bags as required, and tubing was not changed according to facility policy. The therapy room was found to be used for storage of excess equipment, including wheelchairs, walkers, and lifts, which obstructed access to therapy areas such as parallel bars and the plinth. Staff reported having to move equipment before and after therapy sessions, and the room was described as cluttered and dirty by both staff and family members. The air conditioning unit in the therapy room was not functioning, and a ceiling vent was observed to have rust. Staff interviews confirmed ongoing issues with environmental cleanliness and equipment storage, with some staff stating that complaints had been made to management without timely resolution. Additional observations included a resident returning from outside with a urinary catheter bag dragging on the floor, uncovered and wet, which was acknowledged by staff as inappropriate. Housekeeping practices were found to be lacking, with no formal checklist for room checks and the supervisor responsible for multiple roles. Social work staff reported receiving frequent complaints from residents and families about odors and cleanliness. Infection control rounds were documented monthly, but issues persisted in both resident and therapy areas.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Failure to Ensure Accurate Orders and Maintenance for Feeding Tubes
Penalty
Summary
The facility failed to ensure accurate physician orders and proper maintenance of feeding tubes for two residents who required enteral nutrition. For one resident with a history of stroke, oral and throat cancer, and a PEG tube, there were overlapping and unclear orders for tube feeding and water flushes. Documentation was lacking regarding the administration of prescribed tube feedings and water flushes, with no records of Jevity 1.5 or water flushes being provided or refused for several days. Additionally, the order for water flushes was not properly entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in nurses not being prompted to perform or document the required care. The resident experienced severe abdominal pain during an attempted bolus feeding, leading to a hospital transfer and tube replacement. Nurses also expressed confusion about the appropriate volume for flushing the tube and were unaware of the specific orders, further contributing to inconsistent care. For the second resident, who had multiple diagnoses including Parkinson's disease, diabetes, and a feeding tube, physician orders specified tube feeding and hydration but did not include instructions for water flushes to maintain tube patency. Review of the MAR/TAR showed that while tube feedings were documented, there was no documentation of water flushes being performed. Observation revealed that the resident had two PEG tube sites, with the old site showing signs of redness and drainage, and the dressing was not properly dated or initialed. The care plan for this resident addressed nutritional concerns but did not include interventions for maintaining the feeding tube, such as water flushes. Interviews with nursing staff revealed a lack of familiarity with the orders for flushing the PEG tubes and confusion about the documentation process. The facility's policy required that feeding tubes be maintained according to physician orders, including the frequency and volume of flushes, and that care plans address strategies to prevent complications. However, these requirements were not met for either resident, as evidenced by missing or unclear orders, lack of documentation, and incomplete care planning related to feeding tube maintenance.
Failure to Monitor and Document Central Line (Mediport) Care
Penalty
Summary
The facility failed to follow accepted standards of practice for the management and monitoring of a Central Venous Catheter (Mediport) for a resident receiving chemotherapy and radiation therapy for cancer. The resident, who had a history of stroke, left-sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension, and atrial fibrillation, was admitted and readmitted to the facility. Despite having a Mediport placed for chemotherapy, there were no physician orders addressing the Mediport, no documentation in the Medication Administration Records (MAR) or Treatment Administration Records (TAR) regarding its presence, location, or monitoring, and no specific care plan interventions related to the Mediport. Progress notes only briefly mentioned the placement and stability of the Mediport, with no ongoing assessments or documentation of the site or dressing. Interviews with nursing staff confirmed that the Mediport was only accessed and maintained by the Cancer Center staff, and that facility nurses were not monitoring the site for signs of complications such as dressing integrity, bleeding, redness, pain, or warmth. Review of the care plans showed only general skin integrity interventions, with no updates or specificity regarding the Mediport after its placement. The facility provided a policy for flushing, locking, and removing a central line, but did not have a policy for ongoing management and monitoring of a central line, including surveillance for adverse effects.
Failure to Ensure Safe and Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with chronic kidney disease who required regular dialysis treatments. Specifically, there were no physician's orders for dialysis services or for the monitoring and assessment of the resident's dialysis access site. The resident, who had a history of chronic kidney disease, diabetes, hypertension, and other conditions, had a dialysis fistula that was not documented in the physician's orders, Medication Administration Records, or Treatment Administration Records. Additionally, the resident reported issues with bleeding at the dialysis center, but there was no evidence that the facility had orders or protocols in place to monitor or assess the access site upon return. The facility also failed to complete required dialysis communication forms, with most pre- and post-dialysis assessments left incomplete or blank. Out of ten reviewed forms, nine were incomplete and eight lacked any post-dialysis assessment by a nurse. The resident's care plan did not address dialysis services or the presence and monitoring of the dialysis access device. Only one progress note documented a post-dialysis assessment during the review period. These deficiencies were contrary to the facility's own policy, which required ongoing assessment and monitoring before and after dialysis treatments.
Failure to Implement COVID-19 Preventive Measures
Penalty
Summary
The facility failed to implement timely and effective COVID-19 preventive measures during an outbreak, resulting in 11 residents and 10 staff members testing positive for COVID-19. The facility's Pandemic COVID-19 policy, dated 2020, outlined measures such as training staff and isolating infected residents, but these were not adequately followed. The Infection Control Nurse revealed that staff were not fit-tested for N95 masks, and there was no documentation of visitor education on transmission-based precautions. Observations showed that COVID-positive residents were not isolated in private rooms, and staff were not consistently wearing appropriate PPE. During the outbreak, several residents, including those on the Rehab and Long-Term Halls, were not properly isolated, with room doors left open, allowing potential virus spread. Staff members were observed wearing only surgical masks instead of N95 masks, and there was a lack of education on COVID-19 preventive measures. The facility used expired COVID-19 test kits, leading to false positives and delayed identification of actual cases. The Infection Control Nurse admitted to not having documentation of current staff COVID immunizations, and only a portion of the staff had been educated on preventive measures. Resident #7, who required assistance for all activities of daily living and had multiple health conditions, was hospitalized with COVID-19, among other diagnoses. The facility's failure to follow its own policies and CDC guidelines contributed to the rapid spread of COVID-19 among residents and staff. Interviews with staff and administration revealed a lack of communication and adherence to infection control protocols, with the Director of Nursing and Administrator acknowledging that precautions were not followed as they should have been.
Inaccurate Resident Information During COVID Outbreak
Penalty
Summary
The facility failed to ensure accurate resident information on the Resident Roster Matrix (CMS-802) for five residents, which included those who were COVID-positive. This deficiency was identified during a survey when the facility's Social Worker informed the surveyors of a COVID-positive outbreak upon their entrance. Observations during the entrance tour revealed that isolation signs were posted, but the type of isolation was not specified. Additionally, residents were observed moving about and eating in the main dining room, despite the outbreak. The CMS-802 form provided by the facility, dated 10/14/2024, did not indicate any COVID infections, despite the outbreak beginning on 10/10/2024. An interview with the LPN responsible for the Minimum Data Set (MDS) and infection control confirmed that the form was not updated to reflect the COVID-positive status of the residents. This oversight resulted in the likelihood of unmet care needs for the affected residents.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated and revised appropriately with new interventions for four residents, leading to unmet care needs. Resident #7 experienced a urinary tract infection (UTI) and was treated with antibiotics, but her care plan did not include interventions for monitoring signs and symptoms of infection or adverse reactions to antibiotic treatment. She was later sent to the hospital with multiple infections, including a UTI and Covid, which were not addressed in her care plan. Resident #8, who has severe cognitive impairment, was treated for a UTI with antibiotics, but her care plan lacked interventions for monitoring infection signs and symptoms or adverse reactions to the treatment. Similarly, Resident #17 experienced significant weight fluctuations, but the care plan was not updated to reflect these changes or address potential nutritional problems. The care plan was last updated before a notable weight loss, indicating a lack of timely revision. Resident #27 also experienced inconsistent weight changes, with a significant weight gain not triggering any updates in the care plan. The care plan for potential nutritional problems was last updated before the weight gain, showing a failure to revise the care plan in response to the resident's changing condition. These deficiencies highlight the facility's failure to maintain comprehensive and current care plans for residents, resulting in unmet care needs.
Failure to Prevent and Manage Urinary Tract Infections
Penalty
Summary
The facility failed to prevent facility-acquired urinary tract infections and appropriately follow up on contaminated urine samples for four residents, leading to potential health risks. Resident #7, who was urinary incontinent, experienced symptoms of dysuria and fatigue, and was treated with Rocephin for a urinary tract infection. Despite completing the antibiotic course, the resident was later hospitalized with acute metabolic encephalopathy due to multiple infections, including a urinary tract infection and COVID. Resident #8, with severe cognitive impairment, was administered Macrobid for a urinary tract infection before a urine culture was conducted, which later showed Proteus Mirabilis. However, the resident did not meet the McGeers criteria for infection surveillance, indicating a possible misdiagnosis or inappropriate treatment. Similarly, Resident #9 received multiple antibiotics for urinary tract infections over several months, but the McGeers criteria were not met, and no organisms were identified in some instances, suggesting potential overuse or misuse of antibiotics. Resident #31 was treated with antibiotics for urinary tract infections despite urine cultures showing mixed skin/genital flora with no specific organism identified. The facility's Director of Nursing and Infection Preventionist were questioned about staff education on perineal and catheter care, which was last provided in March 2024, indicating a lack of ongoing training to address the high rate of urinary tract infections.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper storage of medication carts, as observed on two separate occasions. The medication carts on the Rehab Hall and Long-Term Hall were found to have dirty drawers containing crushed pills, dust, and loose papers. Interviews with nursing staff revealed confusion about who was responsible for cleaning the carts, with some nurses unsure and others believing it was their duty. The Director of Nursing confirmed that nurses were responsible for cleaning the carts. The facility's Medication Storage policy emphasized the importance of proper sanitation and storage, but these standards were not met. Additionally, the treatment cart on the Rehab Hall was found unlocked and contained several opened and undated medications, including Nystatin powder, Eucerin cream, and Iodosorb gel. This lack of proper dating and security of medications poses a risk of contamination and improper medication administration. Furthermore, insulin and other medications were found without open dates, contrary to the facility's pharmacy guidelines, which require medications to be dated upon opening to ensure they are used within safe timeframes. There were also issues with medication administration practices. Medications were found in a plastic cup in the medication cart without identification of the resident they belonged to, and a medication tablet was mishandled during administration. A resident declined a nasal spray medication, but it was still marked as administered in the Medication Administration Record. These incidents highlight lapses in medication handling and documentation, which could lead to medication errors and compromised resident safety.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as ensure that partially opened food items had an open and use-by date. During a kitchen walkthrough, several issues were identified, including a hand washing sink that was not draining properly, a dirty kitchen floor, and equipment such as a cupboard mixer, toaster, and microwave that were found with dried food particles and crumbs. Additionally, the thickener, hotdog buns, and various food containers in the vegetable refrigerator were found without use-by dates. Eggs were found in the dairy refrigerator without a container or dates. Interviews with staff revealed that the Dietary Manager had been on vacation, and there was a lack of double-checking of food items. The Dietitian noted that recent walk-throughs had revealed undated food items and cleanliness concerns. These deficiencies affected all 35 residents who consumed oral nutrition from the facility kitchen and ice machine, increasing the likelihood of foodborne illness and cross-contamination.
Failure to Analyze Infection Data and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to analyze monthly infection data for July and August, despite having documented infection rates and total numbers of infections. There was no analysis of infection rates, employee call-ins, antibiotic usage, or immunizations. During an interview, the Infection Control Nurse and the Director of Nursing confirmed that no analysis had been conducted from the monthly data collected in the Infection Control program. The facility's Infection Prevention and Control Program and the Infection Preventionist job description both indicated that data analysis was a required component of the infection control program, yet this was not performed. Additionally, the facility did not implement enhanced barrier precautions during wound care for a resident with a chronic wound. During an observation, a wound care nurse and a CNA were seen attending to a resident with a sacrum wound without wearing the required enhanced barrier gowns, despite signage indicating the need for such precautions. The resident had a wound on her bottom, and during the care, blood was noted from a tear at the top of the buttocks crease. The lack of adherence to enhanced barrier precautions increased the risk of cross-contamination and infection spread.
Inadequate Monitoring and Justification of Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and justify the administration of antibiotics for four residents, leading to inappropriate antibiotic use and potential health risks. Resident #7 experienced recurrent urinary tract infections (UTIs) and was administered antibiotics without proper identification of the causative organism. In September 2024, Resident #7 received Rocephin for a UTI caused by Proteus Mirabilis, and in October 2024, Ampicillin was administered without an organism being identified. This lack of proper monitoring and justification for antibiotic use contributed to the resident's recurrent infections and subsequent hospitalization. Resident #8, who has severe cognitive impairment, was administered Macrobid for a UTI despite not meeting the McGeers criteria for infection surveillance. The urine analysis showed Proteus Mirabilis, but the culture was conducted after the antibiotic treatment had already begun. Similarly, Resident #9 received multiple antibiotics for UTIs that did not meet the McGeers criteria, including Keflex, Ceftin, Nitrofurantoin, and Amoxicillin, without proper culture or organism identification. This resident also received Diflucan for a fungal infection/UTI without an identified organism, indicating a pattern of antibiotic use without clinical rationale. Resident #31 was treated with Macrobid and Cipro for UTIs despite urine cultures showing mixed skin/genital flora and no identified organism. The facility's Infection Preventionist and Director of Nursing acknowledged the lack of adherence to McGeers criteria and the absence of a urine dip policy, which contributed to the inappropriate use of antibiotics. The facility's failure to provide ongoing staff education on perineal and catheter care further exacerbated the issue, as the last documented training occurred in March 2024, prior to the summer months when UTI incidents increased.
Failure to Monitor and Document Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and timely provision of care for a resident, leading to a lack of documentation and glucose monitoring during a change in the resident's condition. The resident, an elderly female with a cognitive status of 14 out of 15 on the Brief Interview of Mental Status (BIMS) and a medical diagnosis of diabetes, experienced stomach pain and was on antibiotics for a urinary tract infection (UTI). Despite the completion of antibiotic therapy, the resident continued to feel unwell, and her condition worsened, resulting in her being sent to the hospital. At the hospital, the resident was diagnosed with COVID-19 and a UTI, and her hospital records indicated a sudden change in mental status, low sodium, and critically low glucose levels. The facility's records showed no glucose monitoring or checks at the time of the resident's acute change in condition, which was a significant oversight given her diabetic status. This lack of monitoring and documentation contributed to a delay in identifying and treating her low blood glucose level, which was a critical aspect of her care.
Failure in Timely Weight Monitoring for Residents
Penalty
Summary
The facility failed to ensure timely weight monitoring for two residents, resulting in a lack of follow-up on abnormal weight changes. The facility's 'Weight Monitoring' policy requires a weight monitoring schedule upon admission, with specific guidelines for recording and analyzing weight changes. However, the facility did not adhere to these guidelines, as evidenced by inconsistent weight recordings and a lack of timely re-weighing for significant weight changes. Resident #17 experienced several weight fluctuations in July 2024, including a 7.2-pound loss and a 5-pound gain, without any mention in the physician's progress notes. The resident's care plan, which included potential nutritional problems related to diabetes, dysphasia, Alzheimer's, and chronic kidney disease, was not updated following a significant weight loss. Additionally, the last dietary assessment for this resident was completed in May 2024, indicating a lack of ongoing nutritional evaluation. Resident #27 also exhibited inconsistent weight recordings, with a notable 5.8-pound loss and an 11.2-pound gain. Despite these changes, there was no triggered change in weight generated from the electronic medical record, and the resident's care plan was not updated following the weight gain. Interviews with staff revealed inconsistencies in the method of obtaining weights and a lack of re-weighing within 24 hours for significant weight changes, contributing to the deficiency in weight monitoring.
Failure to Document and Monitor Resident's Behavioral Health Care
Penalty
Summary
The facility failed to ensure proper documentation and monitoring of a resident's behavioral health care, leading to a deficiency in care. The resident, who is unable to make healthcare decisions independently, has a history of epilepsy, intellectual disabilities, schizophrenia, adjustment disorder, major depression, dementia, and delusional disorders. The resident's behavioral care plan, which was undated, noted issues such as yelling, being sexually inappropriate, and attention-seeking behaviors. Despite these documented behaviors, there was no evidence of monitoring or documentation of interventions and their effectiveness in the resident's electronic records. Interviews with the facility's social worker revealed that there was no consistent documentation of the resident's behaviors or interventions in the progress notes. The social worker admitted to the absence of a behavioral program and a lack of policy to monitor such behaviors. Additionally, the facility's Use of Psychotropic Medication policy emphasized the need for assessing underlying conditions and identifying causes, yet there was no evidence of adherence to this policy. The facility administrator later provided a behavioral policy, but it was noted that staff had not been trained on it, indicating a gap in the implementation of behavioral health care protocols.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain appropriate consents for the administration of antipsychotic medications to a resident, identified as Resident #8. The resident was administered Abilify, Trazadone, and Ativan without the necessary consent forms being signed and dated by the responsible party. The facility's policy requires that residents or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments, but this was not adhered to in the case of Resident #8. The social worker attempted to obtain consent by emailing the guardian, but the emails were sent to the wrong address, and the consents remained unsigned. Resident #8 had a diagnosis of dementia, depression, agitation, and sundowning, and was prescribed these medications to manage these conditions. The social worker noted that the resident's guardian was aware of the medication changes, but no formal consent was obtained prior to the administration of Abilify, which replaced Risperdal. The lack of signed consent forms and risk-versus-benefit analysis documentation indicates a failure to comply with the facility's policy on psychotropic medication use, potentially increasing the likelihood of serious side effects and adverse reactions for the resident.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations during a survey. In several resident rooms, there were issues such as extreme odors of urine, used tissues on the floor, stained bedside curtains, and dripping sinks with corrosion. Additionally, there were hazards like missing wood on closet bottoms, bent heater edges, and lifting veneer on room doors. The presence of dirty electric fans, uncovered toothbrushes, and urinals with urine further highlighted the unsanitary conditions. The survey also revealed that some rooms had non-labeled razors, personal items like blankets and pillows on the floor, and opened food bags left unattended. The walls and doors in these rooms had black scuff marks and chipping paint, while the baseboards were lifting. In one room, a CPAP mask was left uncovered, and urinals with urine were placed on the floor. These conditions were observed during two separate walkthroughs, indicating a lack of timely corrective action. Interviews with staff, including a housekeeper and the Director of Nursing (DON), revealed a lack of awareness and responsibility for maintaining the cleanliness of privacy curtains and the overall environment. The facility's hallways and sitting areas also showed signs of neglect, with worn-off finishes and exposed wood. The facility's policy on maintaining a safe and sanitary environment was not adhered to, as evidenced by the observations and the undated daily cleaning sheet that outlined the expected cleaning tasks.
Failure to Provide Scheduled Showers to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively impaired and required assistance with all activities of daily living (ADLs), received the necessary care, specifically showers, as per the facility's policy. The resident, who had a history of stroke with severe cognitive impairment, seizures, anxiety disorder, Alzheimer's Disease, mood disturbance, and diabetes, was supposed to receive two showers a week. However, records showed that the resident only received showers on two occasions and refused one, with no documentation of staff re-approaching the resident or implementing interventions after the refusal. Interviews with the Director of Nursing and staff confirmed that there was adequate staffing to provide the required showers, yet the resident did not receive the scheduled care. The facility's ADL care plan and Resident Showers policy emphasized the importance of maintaining hygiene and preventing skin issues, but these were not adhered to in this case. The lack of documentation and follow-up on the resident's refusal to shower contributed to the deficiency, increasing the likelihood of negative outcomes such as offensive odors, skin issues, and decreased self-esteem with isolation.
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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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