Christian Care Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskegon, Michigan.
- Location
- 2053 South Sheridan Drive, Muskegon, Michigan 49442
- CMS Provider Number
- 235656
- Inspections on file
- 21
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Christian Care Nursing Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents experienced undignified care due to repeated delays in call light responses and staff using personal cell phones during care. One resident waited extended periods for assistance with incontinence care, while another felt ignored as staff texted on personal phones despite facility policy prohibiting such use. These actions failed to uphold resident dignity and timely care.
A resident with Parkinson's disease and cognitive intactness submitted two grievances regarding staff behavior during mealtimes and delayed delivery of condiments, but did not receive any follow-up or written response. Despite the grievances being assigned to the DON with a resolution deadline, facility leadership was unaware of the concerns, and the required grievance process was not followed.
Surveyors found that multidose vials of tuberculin solution in one medication room were not properly dated upon opening, contrary to facility policy and manufacturer instructions. In another unit, an LPN left a medication cart unlocked and unattended, failing to maintain secure storage of medications as required.
Surveyors found that the facility did not consistently follow food safety standards, including improper cooling of cooked foods, excessive sanitizer concentrations, inadequate cleaning of kitchen equipment, and improper storage of food items. These deficiencies were observed during a kitchen inspection and interviews with the Certified Dietary Manager.
Surveyors identified multiple infection control failures, including lack of tracking for staff illnesses, outdated infection control policies, and improper hand hygiene during wound and peri care for several residents. Staff did not follow protocols for glove changes or cleaning of supplies, and a urine sample was improperly stored with medications. The facility also lacked an active water management plan, with no annual review or interdisciplinary team meetings as required.
A resident with multiple chronic conditions experienced significant delays in staff response to her requests for assistance due to an ineffective call light system. The system lacked a visible hallway indicator, and staff had to remove their alert devices during care, leading to further delays. The resident reported pain and frustration from waiting for help, especially when needing to use the bathroom, and resorted to using a metal call bell to get attention when her calls were not answered promptly.
Two residents with pressure ulcers did not receive care consistent with professional standards, including failures in timely and accurate skin assessments, lack of repositioning and moisture management, and improper wound care techniques by staff such as not changing gloves or cleaning surfaces. Documentation of wound care and care planning was incomplete or missing, and staff interviews revealed inconsistent knowledge of required protocols.
The facility did not post daily nurse staffing data in a location accessible to residents and visitors, instead placing it in staff-only areas. Additionally, the facility failed to accurately record the daily resident census and actual hours worked by RNs, LPNs, and CNAs on the staffing data sheets, with inconsistencies in categorization and incomplete documentation.
A resident who was cognitively intact and responsible for their own care was administered an antipsychotic medication without being informed of the reason for its use or the associated risks and benefits. The facility's records did not contain documentation that this information was provided prior to administration, and no evidence of such a discussion was available during the survey.
Two residents experienced delays in the facility's response to their grievances, including unresolved complaints about meal quality and wheelchair comfort. One resident, who was the council president, reported that concerns raised in meetings were not addressed, and there was no evidence of formal grievance forms or prompt written decisions. Additionally, staff failed to communicate and document care instructions for a resident's wheelchair cushion, resulting in ongoing discomfort.
A resident with multiple chronic conditions requested transfer to the ED, and the facility arranged transport without documenting the reason for transfer in the medical record. No assessment or transfer form was completed, and staff stated it was their practice to send residents to the ED upon request without further documentation.
A resident with multiple chronic conditions was transferred to the hospital after requesting evaluation, but there was no documentation that the required written bed-hold policy notice was provided to the resident or their representative. Interviews with the NHA and DON confirmed the absence of documentation, and the facility's policy requiring such notice was not followed.
A resident with dementia and limited mobility exhibited signs of dental pain, but the facility did not adequately assess, monitor, or follow up on her dental care needs. Despite a dental consultation recommending oral surgery, there was no documented follow-up, no care plan focus for dental concerns, and pain assessments did not reflect the resident's reported behaviors. Staff were unclear about monitoring for pain and infection, and the physician was not consistently updated about the resident's dental issues.
A resident with contractures and spastic hemiplegia did not receive consistent application of a prescribed hand splint, as required by their care plan. Staff did not document or ensure the splint was applied, and the resident reported not being asked about wearing it. Therapy staff were unsure if the splint was being used as scheduled, resulting in a deficiency in providing appropriate care to prevent further loss of range of motion.
A resident with dementia and impaired mobility experienced an unwitnessed fall attributed to a malfunctioning anti-rollback wheelchair device. Staff were unaware of the incident and the device issue, and there was no documentation of care or supervision prior to the fall. The facility did not provide a complete investigation, including staff statements or repair records, leading to a deficiency in accident prevention and supervision.
A facility failed to maintain proper accountability and documentation for fentanyl transdermal patches administered to a resident. Review of records showed missing documentation of quantities received, incomplete nurse signatures for patch destruction, and inconsistent entries regarding patch placement and verification. The Director of Nursing was unable to explain the discrepancies, resulting in a lack of clear accountability for the controlled substance.
Surveyors found that a medication room refrigerator contained an opened multidose tuberculin vial that was not dated when opened, and a urine sample for a newly admitted resident was also stored in the same refrigerator. An LPN confirmed the refrigerator should only contain medications and that the vial should have been dated, both actions not in line with facility policy.
A resident was transferred from a wheelchair to bed by two CNAs using a full body electronic lift without any communication or explanation provided to the resident. The resident had a visible wet spot on her buttock, and her wheelchair and cushions had a strong urine odor that persisted even after the cushion cover was removed.
Two residents with cognitive and physical impairments experienced ongoing issues with low-quality incontinence briefs that leaked, requiring double layering and resulting in soiled clothing and wheelchair cushions. Despite repeated complaints from residents, responsible parties, and staff, management was aware of the concerns but did not take effective action to address them.
A resident with significant medical conditions received meals high in sodium from canned and processed foods, despite her responsible party's repeated concerns and requests for a low sodium diet. Facility staff, including the DM and DON, did not assess or monitor the resident's sodium intake, and there was a lack of effective communication and follow-up on the dietary grievances.
Surveyors found that the facility did not maintain enough safe emergency food to meet the needs of its emergency menu. During inspection, the emergency food shelf contained mostly canned vegetables and lacked required entrée items such as Beef Stew, Chili with Beans, Chicken and Dumplings, and Corn Beef Hash, which were listed on the emergency menu but not present onsite. The Certified Dietary Manager stated that some emergency food had been used for regular meals and that the facility was transitioning between menus.
The facility did not have battery-powered emergency lighting installed at the emergency generator transfer switches in the electrical room, as required. This was confirmed during an observation and interview with the Maintenance Director.
Surveyors observed that ceiling tiles were missing from the ceiling grid in the data room, which was confirmed by the Maintenance Director. This failure to maintain the ceiling structure compromised compliance with NFPA 25 standards for automatic sprinkler system maintenance and testing.
Surveyors identified that the facility did not provide the required annual generator preventative maintenance report, with the last documented maintenance occurring over a year ago. This was confirmed by the Maintenance Director during record review, indicating non-compliance with NFPA standards for emergency power system maintenance.
Surveyors observed that the oxygen storage closet contained both full and non-full cylinders mixed together, and combustibles were stored within five feet of oxygen cylinders, in violation of NFPA 99 requirements. These deficiencies were confirmed by the Maintenance Director and could potentially affect multiple occupants if the cylinders were needed during an emergency.
The facility did not ensure proper treatment and care for a resident with a complex medical history, including sepsis, atrial fibrillation, pulmonary hypertension, and recurrent deep vein thrombosis. Despite clear hospital discharge instructions for daily INR monitoring, medication adjustments, daily weights, and strict intake/output monitoring, these protocols were not consistently followed. This led to missed opportunities to address the resident's changing condition, evidenced by a significant weight gain of 24.4 pounds in 13 days.
The facility failed to properly date mark and discard food products, store food correctly, ensure cleanliness of food contact surfaces, air-dry pots and pans, and minimize bare hand contact with ready-to-eat food. These violations were observed during an inspection and affected the safety of food consumed by 49 residents.
The facility failed to implement an effective Infection Control Program, with deficiencies in infection surveillance, staff education on Enhanced Barrier Precautions (EBP), and adherence to infection control policies. A resident on EBP did not receive proper care as staff failed to use required PPE, and the resident was unaware of the precautions.
The facility failed to ensure that pharmacy monthly medication reviews and recommendations were reviewed and acted upon by the attending physician for five residents. The lack of follow-up was confirmed through interviews with the DON and ADON, who admitted that the recommendations were not available and had not been reviewed by the physicians. This resulted in the potential for unnecessary medication to be administered.
The facility failed to ensure that CNAs completed the required 12 hours of in-service training annually. A review revealed that 27 out of 30 CNAs had not completed any assigned training modules, including essential topics like infection control and abuse prevention. Interviews with the HR Director, a CNA, the DON, and the NHA confirmed the staff were behind on their training, and efforts were being made to address this issue.
The facility failed to document and communicate the Advanced Directives for a resident with vascular dementia, resulting in the potential failure to carry out the resident's medical treatment decisions. The resident's wish to be a Do Not Resuscitate (DNR) was not reflected in the Electronic Medical Record (EMR) or on the resident's profile, and the Director of Nursing confirmed that the resident had been missed during a recent audit of code statuses.
The facility failed to notify two residents of the planned discontinuation of Medicare Part A services, resulting in the loss of their right to appeal and potential financial hardship. The required forms were not completed due to the recent departure of the MDS nurse and lack of reassignment of the task.
The facility failed to revise the care plan for a resident with a history of stroke, hemiplegia, and dementia, who displayed loud and teasing behavior during meal times. Despite staff acknowledging the behavior and using humor to manage it, no formal guidance was documented in the care plan or medical record.
A resident with chronic obstructive pulmonary disease and heart failure had a Lidocaine patch placed on the wrong body part by an LPN, who did not consult the physician for an updated order. This action was against the facility's policy and professional standards of quality.
A resident with a history of having only half a colon experienced severe diarrhea followed by constipation due to the facility's failure to implement appropriate bowel monitoring and protocols. The resident was given a daily laxative, leading to diarrhea, and then too much Imodium, causing constipation. The facility's records showed inconsistent documentation and implementation of bowel monitoring.
The facility failed to attempt gradual dose reductions (GDR) of psychotropic medications and ensure PRN psychotropic medications were limited to 14 days for two residents. Monthly pharmacist recommendations were not followed up due to a lack of a system or process in place, resulting in the administration of unnecessary medications.
The facility failed to implement antibiotic use protocols and monitor antibiotic use for a resident diagnosed with a UTI. Despite the resident showing no symptoms, the facility administered Cephalexin without completing a UTI protocol form or obtaining timely lab results. The creatinine clearance was calculated only on the fifth day, and the pharmacy faced difficulties in obtaining necessary data. The facility's antibiotic stewardship policy was not followed, leading to inappropriate antibiotic administration.
The facility failed to complete neurological assessments for a resident who experienced two unwitnessed falls within a short period. Despite the resident's history of stroke and use of anticoagulant medications, no incident report or neurological exams were conducted after the second fall, contrary to facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Dignified Care and Timely Response to Resident Needs
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents who were cognitively intact and had specific care needs. One resident, with a history of congestive heart failure and muscle weakness, was observed to have repeated delays in response to call lights, with documented wait times ranging from 29 to 57 minutes on multiple occasions. The resident reported frequent long waits for assistance, particularly when needing to be changed due to a wet brief, leading to discomfort and embarrassment. Staff interviews revealed that call light notifications were only accessible via electronic tablets or a monitor at the nursing station, and not all staff consistently carried the required tablets, further contributing to delayed responses. Another resident, diagnosed with muscle weakness and chronic obstructive pulmonary disease, reported that staff often used their personal cell phones to text while providing care in the resident's room. The resident expressed feeling ignored and that staff attention was diverted away from her needs during care interactions. The facility had a policy prohibiting the use of personal cell phones in resident care areas, but the resident's account and staff behavior indicated this policy was not consistently followed. These deficiencies were identified through direct observation, resident interviews, staff interviews, and review of facility records and policies. The events described demonstrate a lack of respect for resident dignity and failure to maintain an environment that promotes quality of life, as required by federal regulations. The issues included both delayed response to resident needs and inappropriate staff conduct during care provision.
Plan Of Correction
F550 1. Residents #401 and #10 still currently reside in the facility. The cited residents did not sustain harm from the deficient practice and are at their psychosocial baseline. Their call lights have been evaluated and are working appropriately. 2. Current residents have the potential to be affected by this deficient practice; a sweep was completed on both units to assess the working order of every resident's call light on 6/6/2025. Residents were interviewed regarding observing staff on cell phones in resident rooms on 6/6/2025. Any resident with a concern had a resident concern form filled out on their behalf. 3. Policies on call lights and use of personal cell phones were reviewed and deemed appropriate. Clinical staff have been educated on these policies by 6/6/2025 by the DON/designee. Facility charge nurses were provided with call light receivers to ensure proper notification of call lights. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure call lights are answered timely and staff are not utilizing their personal cell phones in care areas. The Admin/designee will perform a 3x weekly audit on call light receivers to ensure receivers are functioning and audible. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Address and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to follow its own grievance policy in addressing two documented grievances submitted by a cognitively intact resident with diagnoses including weakness and Parkinson's disease. The grievances, both recorded on designated forms, described concerns about nursing staff behavior during mealtimes, including inattentiveness and rudeness, as well as issues with delayed or missing condiments resulting in cold food. Both grievances were assigned to the DON with a specified resolution date, but there was no evidence that the concerns were addressed or communicated to the resident. During an interview conducted more than three weeks after the grievances were filed, the resident reported that no one had discussed the concerns with her since she raised them. She expressed a lack of expectation that her issues would be resolved, indicating a breakdown in the facility's process for acknowledging and resolving grievances as outlined in their policy. The policy requires prompt efforts to resolve grievances, keeping the resident informed of progress, and issuing a written decision, none of which occurred in this case. Further interviews with facility leadership revealed confusion regarding responsibility for grievance management. The DON stated that the NHA handled grievances, while the NHA, identified as the Grievance Official, was unaware of the specific grievance forms and had not seen the paperwork. This lack of communication and adherence to policy resulted in the resident's grievances not being addressed in a timely or effective manner.
Plan Of Correction
F585 1. Resident #29 still currently resides in the facility. The cited resident did not sustain harm from the deficient practice and is at their psychosocial baseline. Resident #29's grievances were resolved. 2. All residents were interviewed during guardian angel rounds to ensure for potential resident concerns by 6/6/2025. Those residents with concerns were provided with a resident concern form and resolved according to the facility grievance policy. 3. The facility IDT was reeducated on the facility grievance policy including grievance documentation, follow-up, and resolution by 6/6/2025. Facility grievance monitoring was added to the morning meeting template for follow-up. 4. The QAPI committee has directed the NHA/designee to perform random weekly audits of the facility grievance log to ensure grievance is resolved according to the grievance policy. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors observed that in the Faith Unit medication room, a multidose vial of opened tuberculin solution did not have an opened date on the vial, box, or packaging. The Registered Nurse (RN) Unit Manager confirmed that staff were required to date multidose vials when opened to ensure timely disposal. In a subsequent observation in the same medication room, another opened tuberculin vial was found without an opened date on the vial, though the box was dated. The RN Unit Manager stated that both the vial and the box should be dated in case they become separated. Manufacturer instructions indicated that vials in use for 30 days should be discarded, highlighting the importance of proper dating. Additionally, in the Love Unit, an unlocked and unattended medication cart was observed. The cart was left unattended while the LPN responsible for it was distracted at the nurse's station and did not lock the cart before leaving. Facility policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with specific requirements for expiration dating and storage. These observations demonstrate failures in medication labeling and secure storage practices as required by federal regulations and facility policy.
Plan Of Correction
F761 1. No specific residents were identified in this citation, both undated TB vaccine vials were discarded immediately upon discovery and the nurse who left the med cart unlocked and unattended was provided on the spot education. 2. The facility provided a sweep of the medication rooms and medication carts by 6/6/2025 to identify improperly dated medications, any found were immediately discarded. 3. The policy on labeling, dating and storage of medications was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on proper procedure, including the importance of securing unattended medication carts by 6/6/2025. Labels were requested from pharmacy for the purpose of ensuring vials are dated appropriately. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of medication rooms and carts to ensure appropriate labeling is done and unattended carts are properly secured. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Deficient Food Safety Practices and Sanitation in Food Service
Penalty
Summary
The facility failed to prepare and handle food in accordance with professional standards for food service safety, as evidenced by multiple observations during a kitchen tour and interviews with the Certified Dietary Manager (CDM). During the inspection, a pan of gravy stored in the walk-in cooler was found at 42°F, and the facility's cooling log showed incomplete entries and improper cooling of roast beef and turkey, which did not reach the required temperatures within the specified time frames. The CDM was unable to confirm whether any improperly cooled food had been served to residents. Additionally, a sanitizer bucket was found to have a concentration well above the required 200-400 ppm, and the chemical dispenser had not been serviced to address this issue. Further observations revealed that clean pans were stored with food debris, and the juice gun spout had an accumulation of debris, with uncertainty from the CDM about whether the spout was properly cleaned. The meat slicer had dried meat shavings, and the mixer had dried cake debris and splatter. The refrigeration unit in the kitchenette had a gasket with black spotted accumulation, and an open container of soy sauce requiring refrigeration was found stored at room temperature in the dry storage room. These findings indicate a lack of adherence to cleaning protocols and proper food storage practices. The report references specific sections of the 2022 FDA Food Code, highlighting the facility's failure to meet standards for cooling, sanitizing, cleaning, and storing food and equipment. The deficiencies observed have the potential to result in foodborne illness among all residents consuming food from the kitchen, as the facility did not consistently follow required food safety procedures.
Plan Of Correction
1. No residents were negatively impacted by this deficient practice. 2. The CDM has re-implemented a food cooling log in accordance with 2022 FDA Food Code section 3-501.15 cooling methods. The facility has repaired the quat sanitizer dispenser to ensure proper concentration of 200-400 ppm. The CDM has implemented a quat sanitizer log to ensure proper concentration under the Code by 4/25/2025. The clean pots and pans under the preparation table were recleaned. The juice gun was recleaned, including removing and disassembling the spout and wiping out the inside. The meat slicer was removed from operation. The mixer was thoroughly cleaned. The top gasket on the refrigerator in the Love Kitchenette was cleaned. The soy sauce identified as half opened was discarded from use. 3. The CDM was educated by the NHA on the Food Safety Requirements Policy and Procedure. All dietary staff were educated on the Food Safety Requirements Policy and Procedure including proper food cooling, proper testing of quat sanitizer, clean food prep surfaces, proper juice gun cleaning, non-food surface cleaning, and proper food refrigeration after opening. These items were added to the daily cleaning log. 4. The QAPI Committee has directed the CDM to perform random weekly audits of proper refrigeration of food items, food cooling temperatures, and cleanliness of food/nonfood contact surface. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by federal regulations. The Infection Preventionist did not track or monitor employee illnesses, which limited the facility's ability to identify and respond to outbreaks, as evidenced by the lack of data on employee sick calls during a COVID outbreak. Infection control policies, including those for influenza and pneumococcal vaccinations, were outdated, with some not reviewed or revised for several years. The facility's infection surveillance policy required tracking of staff infections, but this was not being implemented. Additionally, the facility's infection control policies were not updated annually as required. Direct care observations revealed multiple failures in hand hygiene and infection control practices. During wound care for three residents, staff did not clean bedside tables or use barriers for supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used the same gloves for wound care and peri care. Supplies and equipment, such as wound care scissors, were not properly cleaned or were returned to common carts after being contaminated. Staff interviews indicated a lack of understanding of proper hand hygiene protocols, with some staff and the DON stating that gloves only needed to be changed if visibly soiled, and that urine was not considered a contaminant requiring glove changes. These practices were inconsistent with both facility policy and CDC guidelines. Additional deficiencies were identified in the handling of medications and water management. A urine sample was found stored in a medication refrigerator, contrary to policy requiring separation of potentially harmful substances from medications. The facility also lacked an active and ongoing water management plan to reduce the risk of Legionella and other waterborne pathogens. The Maintenance Director was unaware of key aspects of the water management program, including team membership, control limits for chlorine, and the requirement for annual review and team meetings. The facility's water management policy called for an interdisciplinary team and regular reviews, but these were not being conducted.
Plan Of Correction
1. Resident #1, #4, and #25 continue to reside at the facility and no negative outcomes were identified related to the deficient practice. DPS B A digital testing unit was purchased, and levels remain at acceptable levels as of 4/25/2025. 2. All residents may be impacted by this deficient practice. The facility completed an infection screening evaluation on all residents as of 4/30/2025. Any resident identified with an additional wound or signs/symptoms of an infection will be treated accordingly, and their care plans will be updated. Current residents can be impacted by Legionella. Water levels will continue to be monitored as required. 3. The facility has reviewed the facility Infection Control Plan; this policy is deemed appropriate. The facility's Regional Nurse Consultant educated the DON on proper infection control policies, including hand hygiene. Clinical staff were provided with education on the Infection Control Plan by the DON/designee after the DON educated them, including proper hand hygiene, maintaining a clean work environment, and employee illness management. The ICP has been appropriately educated on infection tracking and trending. 4. The facility has incorporated the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. The Water Management Plan has been updated using the CDC Toolkit, including establishing core members. The Director of Plant Operations educated the members of the WMP on understanding what Legionella is and understanding the facility's water system by 4/30/2025. 5. The QAPI Committee has directed the DON/Designee to perform random weekly audits of proper infection control procedures and tracking and trending. The Committee has also directed the Director of Plant Operations to perform weekly tests for Legionella. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Provide Dignified and Timely Care Due to Ineffective Call Light System
Penalty
Summary
The facility failed to provide care in a dignified manner for several residents, as evidenced by the experience of one resident with multiple medical conditions, including diabetes, stage 4 kidney disease, diverticulosis, irritable bowel syndrome with diarrhea, and urine retention. This resident, who is her own responsible party, reported significant delays in staff response to her requests for assistance, particularly when using the call light system. She stated that the call light system was ineffective, with no visible indicator in the hallway when activated, and that staff relied on portable devices to receive alerts. However, staff were required to remove these devices during care, preventing them from noticing new calls for assistance during that time. The resident described waiting 20 to 30 minutes for staff to respond, which caused her pain and frustration, especially when she needed to use the bathroom. She resorted to using a metal call bell to get attention when her initial call was not answered within 15 minutes. The resident also reported that staff attempted to take away her call bell, but she refused to give it up. These actions and inactions resulted in the resident feeling undignified and dissatisfied with the care provided, as her needs for timely assistance were not met.
Plan Of Correction
F550 1. Residents #5, 30, 35, and 40 still currently reside in the facility. The cited residents did not sustain harm from the deficient practice and are at their psychosocial baseline. Weekly Guardian Angel Rounds have been initiated. 2. Current residents have the potential to be affected by the deficient practice. Residents were interviewed by 4/25/2025 during Guardian Angel Rounds to ensure resident rights were being met and any issues/concerns were addressed and reported. A weekly resident council will be held x 4 weeks to ensure the current residents' needs are addressed. 3. Policy on Resident Rights was reviewed and deemed appropriate, all staff were in-serviced by the Admin/designee by 4/25/2025. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of staff providing care to ensure that resident rights are being observed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Accurately Assess, Monitor, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to follow policies and procedures to accurately assess, monitor, and treat pressure ulcers for two residents. For one resident, the initial skin assessment upon admission documented only a stage 1 ulcer on the gluteal cleft, with no mention of other skin issues. However, subsequent assessments revealed a stage 3 pressure ulcer on the coccyx and multiple open, weeping areas on the buttocks and inner thighs. The resident was observed to be left in the same position for extended periods, was not on a turning schedule despite being unable to reposition herself, and experienced prolonged exposure to moisture and soiled briefs. Staff were unaware of or did not follow a turning schedule, and there was a lack of timely wound care orders and documentation for the identified wounds. The DON could not provide consistent or complete documentation of the resident's wounds or treatments, and excoriated areas were not measured or tracked for improvement or decline. For another resident with a history of a stage III/IV sacral pressure ulcer and high risk for pressure ulcers, deficiencies were observed in wound care practices and documentation. During a dressing change, an LPN failed to use a barrier or clean the table for wound care supplies, did not change gloves or perform hand hygiene between removing the old dressing and applying the new one, and packed the wound with a soiled glove. The resident's brief was saturated with urine and not cleaned prior to the dressing change. There was also a lack of clear documentation of wound care visits and assessments in the medical record, and the care plan did not include meaningful interventions or revisions for the resident's stage III/IV pressure ulcer, such as frequent repositioning or offloading. Interviews with staff revealed inconsistent knowledge and application of infection control and wound care protocols, including hand hygiene, glove changes, and proper handling of wound care supplies. The facility's own policies required full body skin assessments upon admission and weekly, clear documentation of pressure injuries, and clean technique for dressing changes, including cleaning the work surface and changing gloves. These policies were not consistently followed, leading to deficiencies in the prevention, assessment, and treatment of pressure ulcers for the affected residents.
Plan Of Correction
1. Resident #350 no longer resides at facility. The nurse was instructed to complete a wound assessment but failed to do so. This nurse was coached by DON. Resident #1 still currently resides in the facility; no negative outcome was identified due to this deficient practice. Her plan of care has been reviewed to reflect her status. She was assessed and is comfortable. Her wound care documentation is up to date. 2. Like residents are identified as those with pressure injuries. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. 3. The policy and procedure on skin management, along with dressing change policies, have been reviewed and revised. Consultant Nurse educated the DON on assessments and documentation on skin management. Nurses were educated by DON/designee by 4/25/2025 on appropriate management/documentation/care. An admission wound assessment was activated in the EMR. Licensed Nursing staff were educated on completing this assessment on admission. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility with wound injuries to ensure their wounds are properly cared for and documented, and their plan of care/orders addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Properly Post and Record Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. Observations revealed that the daily nurse staffing data sheets for both Faith's Terrace and Love's Garden were posted on bulletin boards facing the nurse's station, making them inaccessible and not visible to residents or visitors passing by. The staffing data sheets were placed alongside other staff-only postings, such as on-call schedules and thank-you cards, further indicating that the information was intended for staff use rather than public access. During interviews, a CNA confirmed that the staffing data sheets were only posted where staff could see them and not where residents or visitors could access them. A review of historic daily nurse staffing data sheets showed that the facility did not consistently record the daily resident census or the actual hours worked by nursing staff by category. Instead, the sheets listed only the scheduled hours and staff names, with inaccuracies such as all nurse hours being entered under the RN category, even when most scheduled nurses were LPNs. The Nursing Home Administrator acknowledged that census numbers and actual working hours were not always recorded on the daily nurse staffing data sheets, and that he kept track of actual hours worked separately.
Plan Of Correction
1. No residents were negatively impacted by this deficient practice. 2. Clear wall paper holders were purchased and mounted in a location on the unit consistent with this requirement and visibility. 3. The Staffing Coordinator was educated on Posted Nurse Staffing Information by the NHA and its requirements including posting the total number of hours worked in real time. The Staffing Coordinator was educated on posting staffing sheets with documented census and updating hours worked upon shift change by the NHA. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of posting nurse staff information including the number of actual hours worked. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and their own responsible party, was administered aripiprazole, an antipsychotic medication, without being informed of the reason for its use or the associated risks and benefits. The resident's medical record, including the Medication Administration Record and electronic documentation, did not contain any evidence that this information was provided prior to the administration of the medication. The resident had diagnoses including dementia and cerebral infarction, and had been receiving aripiprazole since admission. During the survey, the Nursing Home Administrator was unable to provide documentation that the resident had been informed about the medication's purpose or its risks and benefits. Although the administrator indicated that the physician would speak to the resident about the medication, no documentation of such a discussion was available by the time the survey concluded. As a result, the facility failed to meet the requirement to inform the resident in advance about their treatment, including the risks and benefits of the prescribed psychotropic medication.
Plan Of Correction
1. Residents #350 still currently resides in the facility. She was educated on and consented to the use of Abilify on 3/28/2025. 2. Like residents are identified as those who are ordered antipsychotic medications. They have the potential to be affected by this deficient practice. A sweep was completed by 4/23/2025 to ensure all like residents have the appropriate education and consent documented and their plan of care updated as needed. 3. Policy on the use of antipsychotic medications was reviewed and deemed appropriate. Licensed nurses and social work staff were in-serviced between by 4/25/2025 on appropriate procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on residents who are ordered antipsychotic medications to ensure the proper procedure is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Timely Respond to Resident Grievances and Communicate Care Needs
Penalty
Summary
The facility failed to respond in a timely manner to grievances raised by two residents, as evidenced by interviews, observations, and record reviews. One resident, a 90-year-old female with diagnoses including vascular dementia, kidney disease, and major depressive disorder, was not her own responsible party and served as the resident council president. She reported ongoing issues with wheelchair comfort and meal quality, specifically noting a decrease in fresh fruit offerings and dissatisfaction with bread options. Despite her participation in resident council meetings, she was unaware of any formal written grievance forms and expressed that discussions during meetings did not lead to resolutions, stating, "nothing gets done." Review of resident council minutes from several months revealed repeated dietary complaints, including concerns about dessert amounts, meat quality, bread variety, and the availability of fresh fruit and vegetables. These concerns were documented in meeting minutes and a grievance/complaint report was submitted to the Nursing Home Administrator on behalf of the resident council, indicating that concerns were not being fully communicated or resolved. The administrator acknowledged receipt of the grievance but did not provide evidence of prompt resolution or written decisions to the residents as required. Additionally, the occupational therapist confirmed that while a low back cushion had been provided to the resident for wheelchair comfort, there was no documentation or communication to nursing staff regarding its use after therapy ended. The resident continued to experience discomfort and improper positioning in her wheelchair, and nursing staff had not been instructed to perform frequent positioning checks until prompted by the therapist during the survey. These findings demonstrate a lack of timely and effective response to resident grievances and insufficient communication among staff regarding resident care needs.
Plan Of Correction
F585 1. Residents #10 and #40 still currently reside in the facility. Their grievances were immediately documented and addressed between by 4/23/2025. 2. Current residents have the potential to be affected by this deficient practice. A resident council meeting will be held on 4/22/2025, to ensure current residents can express their concerns. A weekly resident council will be held x 4 weeks to ensure the current residents' needs are addressed. 3. Resident Council policy was reviewed and revised. Department heads and facility managers were educated by the Admin/designee between by 4/23/2025 on proper procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on 20% of current residents in the facility, to ensure their concerns are being addressed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Document Reason for Hospital Transfer
Penalty
Summary
The facility failed to document the reason for a resident's transfer to the hospital emergency department in the resident's medical record, as required by federal regulations. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact, as indicated by a BIMS score of 13. On the date of the incident, the resident requested to be sent to the emergency department for evaluation, and the facility arranged for transport after obtaining an order from the on-call healthcare provider. A review of the resident's electronic medical record revealed that, aside from a progress note stating the resident requested to go to the emergency department, there was no documentation indicating the specific reason for the transfer. There was no transfer form, physical assessment, physician communication note, or physician note explaining the medical necessity or rationale for the transfer. The facility's documentation did not provide any further details beyond the resident's request. During interviews, the DON confirmed that a transfer form was not completed for this resident, as the form was a recent addition to their processes. The DON also stated that no assessment was performed prior to the transfer because the resident requested to go, and it was the facility's practice to send residents to the emergency department upon request, regardless of medical necessity. This lack of documentation and assessment led to the deficiency cited by surveyors.
Plan Of Correction
F623 1. Resident #47 no longer resides in the facility, an investigation of the event was completed and the licensed nurse involved received education on appropriate assessment, notification, and documentation of transfers. 2. Like residents are identified as those who are emergently transferred to the hospital. A sweep of like residents for the last 2 weeks was completed by 4/23/2025 to ensure appropriate documentation of the reason for transfer was in place. A Transfer form was added to the facility's EMR system to guide the licensed nurses in appropriate documentation. 3. Licensed nurses were educated on the use of the new Transfer form in PCC to complete which includes, appropriate assessment, notifications, and documentation for all residents who require emergent transfer to a hospital. 4. The QAPI Committee has directed the DON and/or designee to ensure that weekly audits are completed on residents who are transferred out emergently, to ensure the appropriate assessment, notifications, and documentation is completed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Provide Written Bed-Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident or their representative with written notice specifying the duration of the bed-hold policy prior to or immediately following the resident's transfer to the hospital. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact at the time of transfer, as indicated by a BIMS score of 13. Documentation showed that the resident requested to go to the emergency department and was transferred accordingly, but there was no evidence in the medical record that the required bed-hold policy notice was given. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, confirmed that they could not locate any documentation showing that the bed-hold policy had been presented to the resident or their representative. The DON initially stated that the Admissions Coordinator had discussed the policy with the resident and family, but later clarified that there was no documentation of such a discussion. The only related communication found was an email indicating the resident would not be returning to the facility, as they were being transferred to hospice care. A review of the facility's own policy confirmed that written notice of the bed-hold policy should be provided at the time of transfer and a signed copy kept in the resident's file. However, in this case, there was no evidence that the policy was communicated or documented as required, resulting in noncompliance with federal regulations regarding notice of bed-hold policy upon transfer.
Plan Of Correction
Resident #47 no longer resides in the facility. An investigation of the event was completed, and the admissions director received education on appropriate notification and documentation of Bed Hold policy notifications. Like residents are identified as those who have been transferred emergently from the facility. A facility sweep was completed by 4/30/2025 of transferred residents from the last 2 weeks to ensure proper notification of the Bed Hold policy was provided and documentation made in their EMR. The policy for Bed Hold has been reviewed and deemed appropriate. The Business Office Manager has been educated on appropriate processes on 4/23/2025. The QAPI Committee has directed the NHA and/or designee to ensure that weekly audits are completed on 100% of residents who are transferred out emergently to ensure the proper process is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Assess and Monitor Dental Care Needs
Penalty
Summary
The facility failed to adequately assess, monitor, and provide care for a resident with significant dental needs. The resident, who has Alzheimer's disease, dementia, abnormal posture, and is nonverbal with limited movement, was observed exhibiting behaviors such as clenching her shirt and teeth, which her husband identified as signs of pain. Despite a dental consultation indicating the need for diagnostics and oral surgery for a tooth extraction under sedation, there was no documented follow-up by the facility after the initial referral. Nursing progress notes indicated a dental appointment occurred, but no procedures were performed, and there was no evidence of further follow-up or communication with the physician regarding ongoing dental concerns. The resident's care plan did not address dental issues, and pain assessments consistently recorded a pain level of 0/10, despite ongoing reports of pain-related behaviors. Staff interviews revealed uncertainty about monitoring for pain and infection, especially given the resident's inability to express discomfort verbally. There was also a lack of documentation regarding monitoring for infection or updating the physician about the resident's dental needs. The facility did not have a system in place to ensure ongoing assessment and intervention for the resident's dental pain and potential infection, as required by professional standards of practice and the resident's care plan.
Plan Of Correction
F684 1. Resident #30 still currently resides in the facility; Ultram has been ordered for her pain and she is being monitored daily for any s/sx of dental infections. Her plan of care has been updated to reflect her status. Resident #30 is scheduled for tooth extraction. 2. Like residents are identified as those requiring dental services outside the facility. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. Follow-up appointments and responsible party notification were documented by 4/23/2025. 3. Policy on Ancillary Services has been reviewed and revised. Social worker was educated by the DON/designee by 4/23/2025 on appropriate process. Licensed nurses were educated on identification, notification, and treatment of dental pain. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving offsite dental services to ensure they are being monitored for their dental issues and their plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Provide Contracture Care and Ensure Splint Use
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care for contractures in a resident with a history of spastic hemiplegia, contractures, and brain injury. The resident, who is moderately cognitively impaired and dependent on staff for mobility, was observed with contractures in both upper extremities and no splints in place. The resident reported that staff had not applied his hand splints for some time and did not ask if he wanted to wear them. One splint was found across the room, not in use. The care plan indicated the resident should wear a right hand splint for up to four hours at night, but there was no documentation in the electronic medical record task list for staff to chart the application of splints. Interviews with therapy staff revealed uncertainty about whether the resident was wearing the splint as scheduled or if it still fit. Occupational therapy documentation from previous periods indicated a splint wear schedule was in place, but current staff were unsure of its implementation. The lack of documentation and inconsistent application of the splint as per the care plan led to the deficiency in providing appropriate treatment and services to prevent further decrease in range of motion for the resident.
Plan Of Correction
F688 1. Resident #3 still currently resides in the facility; His care plan was reviewed, and orders were entered in order for staff can document the application and removal of his splint. 2. Like residents are identified as those with limited contractures. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. Therapy referrals have been made if indicated, and documentation verification entered for any residents using a positioning device. 3. Policies for ROM and applying splints have been reviewed and revised. Nursing staff and therapy staff were educated by the DON/designee by 4/25/2025 on appropriate process related to this policy. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of residents currently in the facility receiving care for contractures. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Prevent Fall Due to Malfunctioning Wheelchair and Incomplete Investigation
Penalty
Summary
A deficiency was identified when a resident with a history of unsteadiness, vascular dementia, and impaired memory experienced an unwitnessed fall in her room. The incident report noted that the resident was confused, incontinent, and had impaired memory, all of which are predisposing factors for falls. The root cause analysis indicated that the anti-rollback mechanism on the resident's wheelchair was not functioning properly at the time of the fall. Maintenance reportedly fixed the anti-rollbacks after the incident, but there was no documentation provided to confirm this repair or any inspection of other wheelchairs in the facility. Staff interviews revealed that certified nurse aides who cared for the resident before and after the fall were unaware of the incident and did not have knowledge of the anti-rollback malfunction. They stated that a malfunctioning chair would be obvious and that they would not use it if it was not working correctly. The staff also expressed concern that the resident was left unattended in her room, as she had a known history of attempting to self-transfer. The care plan for the resident included multiple fall prevention interventions, but there was no documentation of care or supervision provided immediately prior to the fall. The facility failed to provide a complete investigation of the fall, including staff statements, details of the resident's care and supervision before the incident, and records of wheelchair repairs or inspections. Despite requests from the surveyor, the Director of Nursing did not supply the full investigation or documentation related to the wheelchair's repair or the assessment of other wheelchairs. The lack of thorough investigation and documentation contributed to the deficiency cited under the requirement to ensure the resident environment is as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents.
Plan Of Correction
1. Resident #17 still currently resides in the facility. Her plan of care has been reviewed and she has not had any additional falls. 2. Like residents are identified as those who have experienced a fall within the last two weeks. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. 3. The Policy regarding fall management has been reviewed and deemed appropriate. The NHA and DON were educated on fall investigations, documentation, and follow-up by the Nurse Consultant. Licensed nursing staff were educated by the DON/designee by 4/25/2025 on fall management. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents that experienced a fall in the facility to ensure their intervention was appropriate and the plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Maintain Accountability and Documentation for Controlled Substances
Penalty
Summary
The facility failed to maintain proper accountability and documentation for controlled substances, specifically fentanyl transdermal patches, for one resident. According to facility policy, all controlled substances must be accurately recorded on designated usage forms, with each dose administered and destroyed being witnessed and signed by two licensed staff members. However, review of the Controlled Drug Record sheets revealed multiple discrepancies, including missing documentation of quantities received, incomplete or missing nurse signatures for patch destruction, and instances where patches were signed out twice on the same day or with undated entries. In several cases, only one nurse signed for the destruction of used patches, contrary to policy requirements. Further review of the resident's medication administration records and related documentation showed inconsistent and incomplete entries regarding the placement and verification of fentanyl patches. There were instances where the same nurse signed as both the oncoming and off-going nurse, missing signatures, and lack of clear documentation of patch location or verification that the patch was in place. These documentation lapses made it difficult to accurately reconcile the number of patches dispensed, administered, and destroyed, resulting in a lack of clear accountability for the controlled substance. During an interview, the Director of Nursing was unable to provide a satisfactory explanation for the discrepancies in the documentation and could not account for the missing or improperly documented patches. The facility's failure to follow its own policies and federal regulations regarding controlled substance accountability led to this deficiency, as evidenced by the incomplete and inconsistent records for the resident receiving fentanyl patches.
Plan Of Correction
1. Resident #4 still currently resides in the facility. Her pain levels for the dates in question were reviewed and her pain levels were 0. She is comfortable and denies pain on her assessment. Her patch is in place and signed out appropriately. 2. Like residents are identified as those requiring controlled substance patches. The orders, and documentation of application and removal was reviewed for those like residents. 3. The revised and approved the Destruction of Narcotics policy and procedure. This policy identifies fully used narcotic vs. a narcotic that still has use. This policy further outlines destruction protocols for both. Licensed nurses were educated by the DON/designee by 4/25/2025 on appropriate process. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving controlled pain patches to ensure they are in place and documented appropriately. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Improper Medication Storage and Labeling in Medication Room
Penalty
Summary
Surveyors observed that the Love Unit Medication Room contained a refrigerator with an opened multidose tuberculin vial that was not dated at the time it was opened. When questioned, an LPN was unable to provide information on when the vial was opened and acknowledged that it should have been dated upon opening. This failure to date the medication vial is not in accordance with the facility's policy and accepted professional standards for medication labeling and storage. Additionally, the same refrigerator contained a urine sample belonging to a newly admitted resident. The LPN confirmed that the refrigerator is designated solely for medication storage and that storing a urine sample in this location was inappropriate. The facility's pharmacy policy specifies that potentially harmful substances and non-medication items must be stored separately from medications, and that outdated or improperly labeled medications should be immediately removed from inventory.
Plan Of Correction
F761 1. The Love unit med room refrigerator was immediately audited, all non-medications were removed, and medications/vaccines that were not dated were removed and discarded. 2. A sweep of all med room refrigerators was performed by 4/25/2025 to ensure they are used only for medications and/or vaccines, and all vaccines are labeled appropriately. 3. The policy on Medication labeling and storage was reviewed and deemed appropriate. Licensed nurses were educated on proper procedure by 4/25/2025 by the DON/designee. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure medications are stored appropriately and expired medications are discarded. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Lack of Communication and Inadequate Hygiene During Resident Transfer
Penalty
Summary
Certified Nurse Aides (CNAs) were observed transferring a resident from a wheelchair to bed using a full body electronic lift without communicating with the resident at any point during the process. The CNAs did not inform the resident when they were going to lift, turn, or remove her brief. The resident was awake with eyes open but did not speak during the observation. Upon transfer, a wet spot approximately 3 to 4 inches in diameter was noted on the center of the resident's buttock, and her wheelchair had a strong urine odor. After the cushion cover was removed, the wheelchair and cushions continued to emit a strong urine smell.
Failure to Address Resident Concerns Regarding Incontinence Brief Quality
Penalty
Summary
Two residents with significant cognitive and physical impairments, including Alzheimer's disease, chronic pain, hemiplegia, and psychotic disorder, reported issues with the quality of incontinence briefs provided by the facility. One resident expressed distress about the need for staff to use two briefs at a time to prevent bed soiling, stating that all staff were aware of the problem but no action was being taken. The same resident also voiced concerns about the declining quality of food and the lack of staff response to complaints, indicating that concerns were not being documented or addressed. Another resident's responsible party reported that the new, lower-quality briefs frequently leaked, resulting in increased laundry, more frequent changes, and urine soaking through to clothing and wheelchair cushions. Observations confirmed a strong urine odor on the resident's wheelchair. Both staff and responsible parties indicated that management was aware of the concerns but had not taken effective action to resolve them. Interviews with the DON and NHA revealed awareness of the issues, but no solutions or interventions had been implemented at the time of the survey.
Failure to Address Resident's Dietary Sodium Concerns
Penalty
Summary
A resident with multiple medical diagnoses, including Alzheimer's disease, hemiplegia, heart disease, and psychotic disorder, was admitted to the facility and is not her own responsible party. Her responsible party expressed ongoing concerns about the high sodium content in the resident's meals, noting that the food provided is primarily canned or processed and tastes very salty. Despite repeated complaints and participation in meetings, the responsible party reported that his concerns about the resident's sodium intake, given her medical conditions, were not addressed. The Dietary Manager confirmed that the facility does not offer low sodium diets, only 'no added salt' options, and does not calculate or monitor the resident's daily sodium intake. The DON was aware of general concerns but could not recall specifics or confirm if concern forms were completed, and the NHA was not fully aware of the responsible party's concerns, indicating a lack of effective communication and follow-up regarding dietary grievances.
Insufficient Emergency Food Supplies for Emergency Menu
Penalty
Summary
The facility failed to provide sufficient safe emergency food to meet the requirements of its emergency menu. During a tour of the dry storage room, it was observed that the shelf labeled 'Emergency Food' contained minimal entrée items and mostly canned vegetables, which are typically used to accompany entrée meals. An interview with the Certified Dietary Manager revealed that some of the emergency food had been used to supplement regular menu items before expiration, and the facility was in the process of transitioning between different menus with the assistance of a culinary vendor. A review of the emergency menu showed that items such as Beef Stew, Chili with Beans, Chicken and Dumplings, and Corn Beef Hash were listed, but none of these entrée items were found onsite during the evaluation. This lack of required emergency food provisions was identified through observation, interview, and record review, indicating a failure to maintain adequate subsistence supplies as mandated by emergency preparedness regulations.
Plan Of Correction
E015 1. No residents were harmed as a result of this deficient practice. 2. An emergency food supply was purchased and in the facility by 4/30/2025. 3. The CDM was educated by the NHA by 4/25/2025 on the Emergency Food Supply Policy and Procedure. An emergency food agreement was obtained by the food. 4. The QAPI Committee has directed the CDM/Designee to perform random weekly audits of emergency food supply in the facility. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Provide Emergency Lighting at Generator Transfer Switches
Penalty
Summary
The facility failed to provide automatic emergency lighting in accordance with regulatory requirements, specifically at the emergency generator transfer switches located in the electrical room. During an observation on March 26, 2025, it was noted that there was no battery pack powered emergency light installed at these transfer switches. This deficiency was confirmed through an interview with the facility Maintenance Director at the time of the observation. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K291 1. No residents were harmed as a result of this deficient practice. 2. An emergency battery pack powered light has been installed in the electrical room. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform random audits of facility emergency lighting x 4 weeks to ensure operations. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Deficient Sprinkler System Maintenance Due to Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler system in accordance with NFPA 25 requirements. During an observation on March 26, 2025, it was found that ceiling tiles were missing from the ceiling grid in the data room located in the service hall. This absence of ceiling tiles was confirmed by the facility Maintenance Director at the time of observation. The missing ceiling tiles could interfere with the proper operation of the sprinkler system, as required by the relevant fire protection standards.
Plan Of Correction
K3531. No residents were harmed as a result of this deficient practice. Ceiling tiles in the IT storage closet have been properly installed. Any protrusions through the ceiling tiles have been properly sealed with fire resistant material. The QAPI Committee has directed the Director of Plant Operations/designee to perform random audits of facility x 4 weeks to ensure ceiling tiles are in place according to NFPA 25. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Failure to Maintain Required Annual Generator Maintenance Documentation
Penalty
Summary
The facility failed to maintain its emergency generator system in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. During a record review conducted on March 26, 2025, it was found that the facility did not provide the required annual generator preventative maintenance report. The last available report was dated 3/20/24, indicating that the annual maintenance had not been documented for the current year. This deficiency was confirmed through an interview with the facility Maintenance Director at the time of the record review. The absence of the current annual preventative maintenance report means the facility could not demonstrate compliance with required generator maintenance protocols, which are essential for ensuring the emergency power system's reliability in the event of a main utility power loss.
Plan Of Correction
K918 1. No residents were harmed as a result of this deficient practice. 2. The annual generator preventative maintenance and testing has been completed on 4/3/2025. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly generator load tests as scheduled and submit the results of those tests to QAPI. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Improper Oxygen Cylinder Storage and Proximity to Combustibles
Penalty
Summary
The facility failed to comply with NFPA 99 requirements for the storage of nonflammable gases, specifically oxygen cylinders. During an observation, surveyors found that the oxygen storage closet in the main hall contained both full and non-full cylinders mixed together, rather than segregating empty cylinders from full ones as required. This was confirmed through an interview with the facility Maintenance Director at the time of observation. Additionally, the same oxygen storage closet was found to have combustibles stored within five feet of the oxygen cylinders, which is not permitted under the relevant fire safety standards. These deficiencies were identified during a survey and could potentially affect 17 occupants if the cylinders were needed during an emergency event. The report cites specific violations of NFPA 99 standards 11.6.5.2 and 11.3.2.3(2).
Plan Of Correction
K923 1. No residents were harmed as a result of this deficient practice. 2. The oxygen storage room has been appropriately organized and labeled in accordance with NFPA 99. All cardboard has been removed from the closet and signage has been introduced to keep the area clear. Proper storage racks and locations have clearly been labeled as to the placement of the oxygen containers. All clinical staff will be educated by 4/25/2025 regarding oxygen storage. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly audits of the oxygen room to ensure compliance. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
Oversights in Medication Management and Monitoring for Resident with Complex Medical History
Penalty
Summary
The facility failed to ensure appropriate treatment and care for Resident #49 due to multiple oversights and failures in following admission orders and addressing changes in the resident's condition promptly. Upon admission, R49 had a complex medical history including diagnoses of sepsis, atrial fibrillation, pulmonary hypertension, and a history of recurrent deep vein thrombosis. Despite clear instructions from the hospital regarding the need for daily INR monitoring and adjustments to medications like warfarin and Lasix, the facility did not consistently follow through with these orders. This lack of adherence to crucial medication and monitoring protocols resulted in missed opportunities to address R49's changing condition in a timely manner. The facility's failure to accurately transcribe and implement admission orders is evident in the discrepancies between the hospital discharge instructions and the facility's documentation. Despite recommendations for daily weights, strict intake and output monitoring, and daily PT/INR checks, these orders were not consistently carried out for R49. Additionally, the facility did not adequately monitor R49's weight, leading to a significant 24.4-pound weight gain in just 13 days, indicating a potential worsening of his condition that went unaddressed.
Multiple Food Safety Violations
Penalty
Summary
The facility failed to properly date mark and discard food products, as well as store them correctly. During an inspection, several items in the walk-in cooler were found without dates, including honey ham, ham roll-ups, beef tips and gravy, turkey, hot dogs, and a strawberry smoothie. Additionally, some items were kept beyond their safe consumption dates, such as puréed deviled eggs, French onion dip, BBQ pork, pizza sauce, and butternut soup. In the Faith and Love kitchenettes, thickened beverages were found either undated or past their safe consumption period. These actions are in violation of the 2017 FDA Food Code sections 3-501.17 and 3-501.18, which mandate proper date marking and timely disposal of ready-to-eat, time/temperature control for safety food items. The facility also failed to store food products properly. During the initial tour, boxes of food were observed stored on the floor of the walk-in freezer. This is against the 2017 FDA Food Code section 3-305.11, which requires food to be stored at least six inches above the floor to prevent contamination. Additionally, the facility did not ensure the cleanliness of food and non-food contact surfaces. The inspection revealed an accumulation of debris in a utensil drawer, on the inside top of a microwave, and on clean pots and pans. The microwaves in the kitchenettes also showed significant debris, with one microwave having pitted and chipping surfaces. These conditions violate the 2017 FDA Food Code section 4-601.11, which requires equipment and utensils to be clean to sight and touch. Furthermore, the facility did not adhere to proper procedures for air-drying pots and pans. Several pans were found stacked and stored wet, which is against the 2017 FDA Food Code section 4-901.11 that mandates air-drying of equipment and utensils after cleaning and sanitizing. Additionally, during a meal observation, a Certified Nurse Aide (CNA) was seen using bare hands to fold soft shell tortillas for two residents, which is a direct violation of the 2017 FDA Food Code section 3-301.11. This section prohibits food employees from contacting ready-to-eat food with bare hands and requires the use of suitable utensils or gloves to prevent contamination.
Inadequate Implementation of Infection Control Program
Penalty
Summary
The facility failed to implement and maintain an effective Infection Control Program, particularly in the areas of comprehensive surveillance of facility infections and education on infection control measures. The designated Infection Preventionist (IP) reported not receiving memos from CMS or CDC and had not reviewed new Enhanced Barrier Precautions (EBP) updates. The IP also failed to document staff education on EBP and did not conduct an all-staff in-service on the new information. Additionally, the IP was unable to clearly articulate the facility's surveillance process and inconsistencies were found in the infection logs, including missing symptoms and culture results for residents with infections. Mapping of infections was also incomplete or missing for certain months, which hindered the facility's ability to track and manage infections effectively. Resident #9, who was admitted with diagnoses including an infection due to an indwelling urethral catheter and chronic ulcers, was placed on Enhanced Barrier Precautions. However, during an observation, a Certified Nurse Aide (CNA) failed to don a gown while providing direct care, despite the requirement for gown and gloves under EBP. The resident reported that staff never used the PPE and was unaware of the reasons for the precautions. This indicates a lack of proper implementation and adherence to the facility's infection control policies. The facility's policies on infection surveillance and Enhanced Barrier Precautions were not consistently followed. The Infection Preventionist did not maintain accurate documentation of infections, symptoms, and culture results, and failed to map infections properly. Staff education on EBP was not documented, and the resident involved was not informed about the precautions. These deficiencies highlight significant gaps in the facility's infection control program, putting residents at risk of infection and transmission of communicable diseases.
Failure to Review Pharmacy Recommendations
Penalty
Summary
The facility failed to implement and maintain a process to ensure pharmacy monthly medication reviews and recommendations were reviewed and acted upon by the attending physician for five residents. The medical records for these residents showed that the consultant pharmacist made non-significant recommendations, but there was no documentation indicating that these recommendations were conveyed to or reviewed by the physician. This lack of follow-up was confirmed through interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who admitted that the recommendations were not available and had not been reviewed by the physicians. The DON also revealed that the pharmacy recommendations had been going to a spam folder and that there was no system in place to review them. For Resident #2, the pharmacy notes from 12/20/23 and 1/24/24 contained recommendations that were not reviewed by the physician. Similarly, for Resident #24, the pharmacy note from 3/13/24 was not reviewed. Resident #30 and Resident #42 had pharmacy notes with recommendations on multiple dates, none of which were followed up by the physician. Resident #9 had pharmacy notes with recommendations on 1/24/24 and 3/13/24, but there was no evidence of physician follow-up. The failure to review and act upon these recommendations resulted in the potential for unnecessary medication to be administered to these residents.
Failure to Ensure CNAs Completed Required In-Service Training
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) completed the required 12 hours of in-service training annually. A review of the Employee Online Inservice Training competencies report revealed that out of 30 CNAs, 27 had not completed any of the assigned training modules. These modules included essential topics such as body mechanics, fire safety, HIPAA privacy, infection control, pressure ulcers risk control, resident rights, abuse prevention, and dementia care, among others. Interviews with the Human Resources (HR) Director, a CNA, the Director of Nursing (DON), and the Nursing Home Administrator (NHA) confirmed that the staff were behind on their mandatory training and that efforts were being made to address this issue. The facility's policy on the Nurse Aide Training Program, revised in December 2022, mandates that each nurse aide must complete at least 12 hours of in-service training annually. This training is crucial for ensuring the continuing competence of nurse aides and includes topics such as effective communication, dementia management, abuse prevention, infection control, and safety procedures. Despite this policy, the facility did not ensure compliance, resulting in a potential for inadequate and substandard quality of care for residents. The HR Director acknowledged the issue and reported that she was working with staff to get them caught up on their training requirements.
Failure to Document and Communicate Advanced Directives
Penalty
Summary
The facility failed to ensure that Advanced Directives were properly documented and communicated for one resident, resulting in the potential failure to carry out the resident's medical treatment decisions. Resident #19, who had vascular dementia, was readmitted to the facility after a hospitalization. The Medical Treatment Decisions of Resident form, signed by the resident's responsible party and the Medical Director, indicated that the resident did not wish to have cardiopulmonary resuscitation (CPR). However, this code status was not reflected in the Electronic Medical Record (EMR) or on the resident's profile. During an interview, the Director of Nursing (DON) confirmed that there was no order reflecting the resident's Advanced Directives and wish to be a Do Not Resuscitate (DNR). The DON acknowledged that without such an order, staff would not be able to quickly identify the appropriate actions to take in the event of cardiac arrest. The DON also mentioned that the facility had recently conducted an audit of each resident's code status, but Resident #19 had been missed.
Failure to Provide Notification of Medicare Part A Coverage Discontinuation
Penalty
Summary
The facility failed to provide notification of planned discontinuation of coverage for Medicare Part A services for two residents, resulting in the loss of the right to appeal the determination and the potential for unforeseen obligation and hardship. Resident #1 received Medicare Part A Skilled Services from February 8, 2024, through March 27, 2024, and Resident #40 received these services from March 26, 2024, through April 9, 2024. In both cases, the facility initiated the discharge from Medicare Part A Services before benefit days were exhausted, but the required notification forms (CMS-10055 and CMS-10123) were not completed or provided to the residents. This omission was confirmed through a review of the SNF Beneficiary Notification Review forms and interviews with facility staff. The Admissions Director reported that the MDS nurse responsible for completing the notification forms had recently quit, and the task was not reassigned to another staff member. The Director of Nursing confirmed that the required forms were not being completed by the outside agency MDS nurse covering the facility. The Nursing Home Administrator also acknowledged the lapse in completing the required notifications. This failure to provide proper notification resulted in the residents losing their right to appeal the discontinuation of Medicare Part A services and potentially facing unforeseen financial obligations.
Failure to Revise Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to revise the Plan of Care for a resident (R10) who displayed behaviors affecting others. R10, admitted with a history of stroke, hemiplegia, and dementia, was observed during multiple meal services engaging in loud, gregarious, and teasing conversations with staff and another resident (R12). Despite R12's lack of engagement and occasional complaints about R10's rude remarks, the facility did not update R10's care plan to address these behaviors. Staff acknowledged R10's behavior and mentioned using humor to manage it, but no formal guidance was found in the care plan or medical record on how to handle the behavior while preserving R10's dignity and ensuring a pleasant dining experience for other residents. Interviews with the Assistant Director of Nursing (ADON) and Social Worker (SW) revealed that R10's behavior was known but not documented in the care plan. The ADON mentioned that R10's daughter had informed them about his different sense of humor, which was not appreciated by other residents. However, no information was found in the medical record or care plan addressing this behavior. The lack of documentation and guidance on managing R10's behavior led to the deficiency noted in the report.
Failure to Follow Physician's Order for Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of quality for Resident #38, who was admitted with diagnoses including chronic obstructive pulmonary disease and heart failure. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for a Lidocaine External Patch to be applied to the right upper back. However, an LPN placed the patch on the resident's right upper arm instead, following the resident's request, without consulting the physician or obtaining an updated order. This action was confirmed through interviews with the LPN, the Director of Nursing, and the Nursing Home Administrator, all of whom acknowledged that the patch should have been placed according to the physician's order on the right upper back. The deficiency was further documented in an Employee Coaching report, which detailed the LPN's deviation from the physician's order and the facility's policy on medication administration. The facility's policy, revised on 3/31/2022, mandates that medications must be administered in accordance with orders. The failure to follow the physician's order for the Lidocaine patch placement resulted in a potential risk for the resident's well-being, as the professional standards of quality were not adhered to.
Failure to Implement Appropriate Bowel Monitoring and Protocols
Penalty
Summary
The facility failed to ensure appropriate bowel monitoring and protocols for a resident, resulting in severe diarrhea followed by constipation. The resident, who had a history of having only half a colon and did not use laxatives prior to admission, was administered a daily laxative for over a week, leading to severe diarrhea. Despite the resident's Power of Attorney (POA) informing the facility that the resident used Imodium instead of laxatives, the facility continued with the laxative administration. Subsequently, the resident was given too much Imodium, causing severe constipation. The facility's records showed that the resident did not have a bowel movement for 11 days, despite having multiple loose stools in one morning, which was not documented properly. Interviews with staff revealed that the facility's bowel protocol was not followed consistently, and there were issues with the documentation and implementation of bowel monitoring. The Director of Nursing (DON) acknowledged that the Imodium order was incorrectly entered and that some nurses failed to run the bowel report, leading to the resident's prolonged constipation.
Failure to Implement GDR and Limit PRN Psychotropic Medications
Penalty
Summary
The facility failed to attempt gradual dose reductions (GDR) of psychotropic medications and ensure PRN psychotropic medications were limited to 14 days for two residents. Resident #30, who was admitted with Alzheimer's disease, anxiety, and depression, was prescribed sertraline, trazodone, and quetiapine fumarate. Monthly pharmacist reviews recommended dose reductions, but there was no documentation of GDR attempts or risk versus benefit considerations in the resident's medical record. The Director of Nursing (DON) admitted that pharmacist recommendations had not been followed up due to a lack of a system or process in place, and the recommendations were going to a spam folder. Resident #42, admitted with Alzheimer's disease, anxiety, and right-sided hemiplegia, had an order for Ativan with no end date. Monthly pharmacist reviews recommended evaluating the necessity of the PRN medication and providing a risk versus benefit statement, but there was no follow-up documentation. The DON confirmed that Ativan should not be ordered PRN with no stop date and acknowledged the lack of a system to review pharmacist recommendations.
Failure to Implement Antibiotic Use Protocols
Penalty
Summary
The facility failed to implement antibiotic use protocols and a system to monitor antibiotic use for a resident diagnosed with a urinary tract infection (UTI). The resident was admitted with multiple diagnoses, including dementia and COPD, and was prescribed Cephalexin for a UTI diagnosed in the hospital emergency department. Despite the resident showing no signs or symptoms of a UTI, the facility proceeded with the antibiotic treatment without completing a UTI protocol form or obtaining necessary laboratory results in a timely manner. The creatinine clearance, which is essential for adjusting antibiotic dosage, was calculated only on the fifth day of antibiotic administration, and the pharmacy faced difficulties in obtaining the required laboratory and patient values from the facility. This delay in obtaining and acting on critical information led to the inappropriate administration of antibiotics to the resident. The facility's policy on antibiotic stewardship was not followed, as evidenced by the lack of adherence to established protocols and the failure to monitor antibiotic use effectively. The medical director and nursing staff did not ensure that antibiotics were prescribed and administered appropriately, resulting in potential risks to the resident's health.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure appropriate neurological assessments were completed for a resident who experienced two unwitnessed falls within a short period. The resident, who had a history of stroke, high blood pressure, osteoporosis, and a traumatic fracture, was on anticoagulant medications. After the first unwitnessed fall, neurological exams were performed as per the facility's policy. However, after the second unwitnessed fall, no incident report was filed, and the neurological assessments were not restarted as required by the facility's protocol. During interviews, a Registered Nurse confirmed the absence of an incident report and neurological assessments for the second fall. The Director of Nursing also acknowledged that the expectation was to restart neurological exams after any unwitnessed fall with a known or suspected head injury. The failure to follow these protocols resulted in the potential for a delay in treatment after an unrecognized acute change in the resident's condition.
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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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