Corewell Health Rehabilitation & Nursing Center -
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevensville, Michigan.
- Location
- 4368 Cleveland Ave, Stevensville, Michigan 49127
- CMS Provider Number
- 235164
- Inspections on file
- 21
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Corewell Health Rehabilitation & Nursing Center - during CMS and state inspections, most recent first.
A resident with Alzheimer's dementia and a history of falls was prescribed lorazepam without adequate indication, monitoring, or consent. After starting the medication, the resident experienced multiple falls, culminating in a severe fall that caused pelvic fractures and death. The facility did not review the medication's role in the falls, failed to monitor for adverse effects, and did not obtain required consent, leading to significant harm.
A resident with dementia, left-sided paralysis, and chronic pain, who preferred to stay up late, was forced by staff to go to bed despite her resistance. During the process, she became agitated and combative, leading to multiple staff interventions. After being transferred to bed, the resident complained of severe left shoulder pain, and was later diagnosed with a fractured humerus. Staff interviews confirmed that her preferences were not honored, and her right to self-determination was not supported, resulting in frustration, an altercation, and injury.
A resident with Alzheimer's dementia and related conditions was administered Lorazepam without documented informed consent from their representative. The care plan lacked interventions for psychotropic medication use, and facility staff could not provide evidence of written or verbal consent, resulting in the resident's representative being unaware of the medication administration.
A resident with dementia and high fall risk did not consistently have a fall mattress properly placed next to the bed as required by the care plan and facility policy. Staff failed to ensure the intervention was in place, with interviews revealing miscommunication and lapses in following procedures, resulting in the resident being left without the intended fall protection.
Two residents with indwelling catheters were observed with catheter tubing and drainage bags in contact with the floor, contrary to facility policy. One resident's catheter bag was found resting on the floor while in bed, and another resident was seen self-ambulating with catheter tubing and a privacy bag dragging on the ground. Both residents had medical histories that increased their risk for infection, and one had recent evidence of a urinary tract infection.
The facility failed to maintain professional standards for food safety, with issues including debris accumulation in kitchen equipment, improper food storage, and inadequate temperature control. The ice machine and microwave were found with debris, and utensil drawers were not clean. Food items were improperly stored, with soy sauce not refrigerated and dish machine temperatures below required levels. Additionally, leftover food was not cooled or stored correctly, posing a risk of foodborne illness.
The facility was cited for deficiencies in its infection prevention and control program, including inadequate water management and improper hand hygiene practices. Maintenance staff were unaware of regular flushing procedures, leading to discolored water in several areas. Additionally, staff failed to use proper PPE during resident care, such as G-tube medication administration and incontinence care, increasing the risk of cross-contamination.
The facility failed to document advance directives accurately for three residents, leading to potential non-compliance with their medical care preferences. A resident had a DNR order without signed paperwork, another had incomplete documentation with a DNR form signed by the wrong advocate, and a third had a DNR order without signed documentation from the resident and physician. The social worker and nursing home administrator acknowledged the documentation issues.
A resident with multiple health conditions was found in a room with a heavily soiled mattress and damaged walls, indicating a failure to maintain a clean and safe environment. Interviews with staff revealed communication and follow-up issues regarding maintenance and cleanliness, with no evidence of completed work orders and insufficient maintenance personnel.
The facility failed to transmit MDS discharge assessments timely for two residents, leading to potential inaccuracies in discharge tracking. One resident's assessment was incomplete with sections GG, J, M, N, O, and P pending, while another's had section K pending. An MDS nurse confirmed the assessments should have been completed and transmitted by specific dates.
A facility failed to complete a PASARR Level II assessment for a resident with severe cognitive impairment and mental health diagnoses, despite the need being identified in a Level I assessment. The social worker could not provide documentation of the Level I assessment or a completed Level II assessment, resulting in potential unmet mental health care needs.
A facility failed to develop a Hospice care plan for a resident with dementia and Alzheimer's disease, who had a severely impaired cognitive status and was receiving Hospice care. The MDS nurse misunderstood the responsibility for completing the care plan, leading to a deficiency in person-centered care planning.
A resident with severe cognitive impairment and dependence on staff for ADLs was observed with long, dirty fingernails, indicating a failure in nail care provision. Despite the resident's preference for clean nails, staff inconsistently provided care, with some CNAs stating it should be done during showers. An LPN acknowledged the need but did not complete the task due to time constraints. The DON expected nails to be clean, but there was no documentation of care, leading to the deficiency.
A resident with CHF and a pacemaker was not administered Lasix as ordered upon admission to the facility, leading to significant weight gain and worsening of his condition. Despite attempts to communicate the need for the medication, it was not consistently provided, resulting in hospitalization for fluid overload. The facility failed to report significant weight changes to the physician or adjust the diuretic medication, contributing to the resident's deteriorating condition.
Two residents at risk for pressure injuries did not receive adequate preventative care in a facility. One resident, with a history of pressure injuries, was often improperly positioned in a wheelchair without secure pressure-relieving boots, leading to a pressure ulcer on the heel. Another resident spent extended periods in a wheelchair without a pressure-reducing cushion, contrary to their care plan. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to care plans and professional standards for pressure ulcer prevention.
The facility failed to control hot water temperatures, allowing them to exceed safe limits, and did not ensure safe transfers for two residents. One resident was transferred without a gait belt or additional staff, while another was transferred with an improperly attached hoyer sling, risking their safety.
Two residents with indwelling foley catheters did not receive proper care, leading to potential risks of catheter dislodgement, pain, and infection. One resident was not toileted as per her care plan and had an unsecured catheter causing discomfort. Another resident's catheter was not secured, and incontinence care was performed without changing gloves after contact with feces, risking cross-contamination. These deficiencies were observed during staff interviews and direct observations.
A resident with COPD was found with an empty water bottle on her oxygen concentrator, which was still running. The oxygen tech reported a delay in scheduled maintenance, and facility staff had differing views on who was responsible for monitoring the equipment. This led to a deficiency in ensuring proper maintenance of the oxygen delivery system.
A facility failed to ensure a physician documented review and follow-up on pharmacy recommendations for a resident, leading to potential medication side effects and unnecessary medications. The resident had several pharmacy recommendations, including changes to Lidoderm orders, re-evaluation of duplicate therapy, and adjustments to insulin and Zoloft dosages, which were not addressed by the physician. The facility's policy required timely action on pharmacy reports, but the physician's response was left blank, indicating a deficiency in medication management.
Surveyors observed that the facility did not have a battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110. This deficiency was confirmed with the Maintenance Technician and could impact access to emergency equipment during a generator failure.
Surveyors found that doors to the Therapy storage closet and a back hall storage closet used for emergency food and water did not self-close to a positive latch as required by LSC 19.3.2.1. These deficiencies were confirmed during interviews with the Maintenance Technician and could potentially affect 20 occupants if a fire were to occur.
A smoke barrier door near a resident room was found to be improperly aligned, causing it to bind on the floor and preventing it from self-closing or releasing when the fire alarm was activated. This issue was confirmed by the Maintenance Technician during the survey.
A resident with a history of dysphagia and choking incidents died after choking on food due to inadequate supervision and safety measures. Despite being on a specialized diet, the resident chose to eat foods not suitable for his condition. The facility failed to enforce the care plan requiring communal dining for supervision, especially during a COVID-19 outbreak when the main dining room was closed. Staff were unaware of the need for increased supervision, leading to the resident's death from choking.
Failure to Monitor and Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications without adequate indication and failed to monitor a resident for adverse effects after initiating such medication. A female resident with severe late-onset Alzheimer's dementia, a history of recurrent falls, insomnia, and depression was prescribed lorazepam daily. Prior to the prescription, the resident had not experienced any falls since her admission in February. After starting lorazepam, the resident experienced multiple falls in May, with no major injuries initially, but there was no evidence that the facility reviewed her medications or monitored for adverse consequences following these incidents. Documentation revealed that the resident's care plan identified her as being at risk for falls due to impaired balance and the use of psychoactive medications, but there was no policy or clear intervention for visual checks or monitoring for medication side effects. Behavior logs and care plans did not show a focus on monitoring psychotropic medications, and there was no documented increase in wandering or agitation prior to the medication change. The resident's family was not informed or asked for consent regarding the addition of lorazepam, and there was no documentation of consent for the medication. Staff interviews indicated that the resident was independent, not aggressive or combative, and could be redirected, with no significant behavioral escalation documented prior to the medication change. After the initiation of lorazepam, the resident experienced a significant fall resulting in an impacted acetabulum and pelvic fracture, leading to hospitalization and subsequent death. There was no indication that the facility reviewed the resident's medications after each fall to determine if they contributed to the incidents. The consultant pharmacist was not made aware of the increase in falls after the addition of lorazepam, and the facility's medication management policy was not effectively implemented to ensure monitoring and prevention of unnecessary drug use. The lack of monitoring, failure to obtain consent, and absence of medication review after falls directly contributed to the deficiency.
Removal Plan
- Review all residents' charts to identify residents on psychotropic medication to ensure adequate monitoring.
- Create worklist tasks for all residents on psychotropic medications to monitor for adverse reactions, specifying medication class and symptoms to monitor.
- Audit all residents on psychotropic medications for consent forms; complete consent forms for any resident missing one and obtain signature.
- Upload completed consent forms to Epic.
- Educate the Medical Director on F605 regulations, with emphasis on the appropriate use of psychotropic medications.
- Provide a list of all residents on psychotropics to the Medical Director.
- Educate the Nurse Practitioners on F605 regulations.
- Review behavior logs during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents.
- Educate nurses regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics.
- Educate the social worker on the expectation to implement non-pharmacological interventions, and educate the second social worker.
- Re-educate nurses, led by the DON, for all nursing leaders and on-duty staff; do not permit any nurse to work until this education is completed.
- The DON or designee will pull an Epic report to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place.
- Review new symptoms during the IDT meeting and communicate to providers using the SBAR format.
- Educate social workers on obtaining consent for psychotropic medications; re-educate one social worker and re-educate the second.
- Educate the consultant pharmacist on the medication review process and confirm understanding.
Failure to Honor Resident's Right to Bedtime Choice Results in Injury
Penalty
Summary
A resident with a history of chronic pain, left upper arm contracture, debility, stroke, left-sided paralysis, and dementia was reviewed for her right to self-determination and choice. The care plan noted that the resident may refuse to return to her room for incontinence care or go to bed at a reasonable time, with interventions to assess decision-making ability and provide a consistent routine. Despite this, staff attempted to put the resident to bed between 9:00 PM and 10:00 PM, although she was known to resist going to bed and preferred to stay up. During the process of undressing her and preparing her for bed, the resident became agitated, fought with staff, and began swinging her arm. Staff left the room to seek assistance, and multiple CNAs attempted to help, but the resident continued to resist and became increasingly upset. Subsequently, the resident was transferred to bed using a Hoyer lift by another CNA, during which she was observed to be crying and calling staff names. Later, the resident complained of severe pain in her left shoulder, which was assessed by nursing staff and found to be swollen and tender. She was sent to the emergency department, where imaging revealed a closed fracture of the surgical neck of the left humerus. The resident reported to staff and emergency personnel that her arm had been pulled during care, and she repeatedly stated that her arm was broken by staff. Staff interviews confirmed that the resident was typically resistive to going to bed and that her preferences were not accommodated on the night of the incident. Observations and interviews with staff and the resident indicated that her right to make choices about her bedtime and care routine was not honored. Staff acknowledged that the resident preferred to stay up late and often refused to go to bed, but on the night in question, they proceeded with care despite her resistance. The failure to respect the resident's choices and to re-approach her at a later time contributed to her agitation and the subsequent altercation, which resulted in a significant injury.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for one resident with severe late onset Alzheimer's dementia, agitation, insomnia, and depression. Review of the resident's care plans showed no focus or interventions related to the use of psychotropic medications or monitoring for adverse consequences. Multiple orders for Lorazepam were present in the resident's record, but there was no documented consent for these medications, either written or verbal. The resident's family member and Durable Power of Attorney (DPOA) was not aware that the resident was receiving Lorazepam and reported not having given permission for its use. Interviews with facility staff revealed that the process for obtaining and documenting consent was inconsistent and lacked a standard procedure. The social worker was unable to locate any notes indicating that consent had been obtained for the prescribed Lorazepam, and the nurse liaison confirmed there was no documentation of verbal consent in the resident's record. The absence of proper documentation and communication resulted in the resident or their representative not being fully informed or able to make decisions regarding the risks, benefits, and alternatives to the prescribed psychotropic medication.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions and follow facility policy to prevent falls for a resident with dementia, confusion, incontinence, reduced mobility, and end-stage Alzheimer's disease. The resident was identified as a fall risk, and the care plan included interventions such as keeping the bed in a low position, placing a fall mattress next to the bed, and conducting regular visual checks. Despite these interventions being documented, staff did not consistently ensure the fall mattress was properly positioned next to the bed as required. On one occasion, a CNA observed the resident attempting to get out of bed and sliding to the floor, after which additional fall prevention measures were added, including placing one side of the bed against the wall and using a full-thickness mattress on the open side. However, during a later observation, the fall mattress was found standing on its side rather than lying flat on the floor next to the bed. Staff interviews revealed that the CNA forgot to lay the mattress down after removing the resident's roommate, and the LPN assumed the CNA would do it, resulting in the intervention not being in place as intended. The facility's policy required that interventions to prevent falls be implemented and care plans updated as needed. Despite the resident's high risk for falls and the documented need for a fall mattress, staff failed to consistently follow the care plan and policy, leaving the resident without the required fall protection at the bedside. This lapse in following established interventions and policy contributed to the deficiency cited by surveyors.
Failure to Maintain Catheter Tubing and Drainage Bags Off the Floor
Penalty
Summary
The facility failed to prevent the risk of urinary tract infection by not ensuring that urinary catheter tubing and drainage bags were kept off the floor for two residents with indwelling catheters. One male resident with a history of stroke and gross hematuria was observed lying in bed with his catheter bag resting directly on the floor without a barrier. This was confirmed by an LPN, who subsequently placed a towel under the bag. The clinical nurse supervisor confirmed the resident had a Foley catheter, which had last been changed the previous month. A female resident with dementia, insomnia, and diabetes was observed self-ambulating in her wheelchair with her catheter bag in a privacy bag, but with approximately 12 inches of catheter tubing dragging on the floor. Multiple observations confirmed that both the tubing and the privacy bag containing the catheter bag were in contact with the floor as she moved around the facility. The urine in the tubing appeared dark yellow, orange-tinged, and cloudy. Staff interviews confirmed that this resident had recurrent urinary tract infections, and a recent urinalysis showed evidence of infection. Facility policy requires that catheter tubing and drainage bags be kept off the floor, but this was not followed in these cases.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The Certified Dietary Manager (CDM) revealed that maintenance staff and an external vendor were responsible for cleaning the ice machines. However, an inspection of the ice machine's dispensing spout showed a significant accumulation of black and brown debris. Additionally, the microwave in the main kitchen had a buildup of debris and chipping surfaces, and utensil drawers contained crumb debris. These conditions indicate a lack of proper cleaning and maintenance, which could lead to food contamination. Further observations revealed improper storage and temperature control of food items. An open gallon container of soy sauce was stored under a preparation table despite instructions to refrigerate after opening. The dish machine was not consistently reaching the required minimum wash temperature of 160°F, as evidenced by multiple cycles showing temperatures below this threshold. The CDM admitted that staff were not diligent in maintaining logs to ensure the dish machine's proper functioning, and the device used to test the machine was reportedly malfunctioning. The facility also failed to properly cool and store leftover food items. During a review of the walk-in cooler, items such as chili, creamy vegetable soup, and cooked pork loin were found at temperatures above the recommended 41°F. The CDM was unsure of the cooling methods used and decided to discard the items. A subsequent visit found a pan of pork gravy at 69°F, which was also discarded. These findings highlight a lack of adherence to FDA Food Code standards for cooling and storing food, potentially leading to foodborne illnesses among residents.
Plan Of Correction
Element #1 No specific Residents were identified in citation. Ice Machine and Dish Machine were serviced/cleaned by vendor, microwave was replaced. Utensil drawers were cleaned of debris, floor area behind ice machine has been cleaned. Soy Sauce disposed of at time of observation. Observed gallon of chili, vegetable soup and pork loin discarded at time of observation. Element #2 Residents residing in facility who have food prepared in the dietary department have potential to be affected. Element #3 Nutrition Services staff have re-educated on 2017 FDA food Code sections 4-601.11, Food Contact, Section 3-501.16 Time/Temp control for safety food hot/cold handling by CDM. Element #4 Nutrition Services Manager/designee will complete random weekly sanitation audits, cooling log and Dish Temperature audits. Variances will be addressed at the time of observation. Weekly audits to be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, specifically related to the management of water systems and hand hygiene practices. During a tour, it was observed that the facility lacked an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. Maintenance staff were unaware of regular flushing procedures for unused water fixtures, and brown, discolored water was observed in several areas, indicating a lack of routine flushing. Additionally, the facility did not have an active team overseeing the water management plan, and there was uncertainty about the permitting of the secondary treatment system. Infection control practices were also found to be lacking during resident care. For instance, a CNA was observed providing incontinence care to a severely cognitively impaired resident without changing gloves or performing hand hygiene between dirty and clean tasks. Similarly, an RN and an LPN failed to use proper PPE during G-tube medication administration and dressing changes for residents under enhanced barrier precautions. The RN did not change gloves or perform hand hygiene while handling various items and performing tasks, and the LPN did not wear a gown during medication administration, contrary to facility policy. The facility's infection control policy requires enhanced barrier precautions, including gown and glove use, during high-contact care activities. However, staff interviews revealed a lack of understanding and adherence to these precautions. The Director of Nursing and the Staff Educator/Infection Preventionist acknowledged the need for proper PPE use and hand hygiene but noted that glove use during incontinence care was not frequently audited. These deficiencies highlight significant lapses in infection control practices, increasing the potential for cross-contamination and disease transmission among residents.
Plan Of Correction
DSP A Element #1 No residents identified. Element #2 Residents residing in the facility have the potential to be affected. Front and Back 200 Spa rooms have been flushed to include tubs and commodes. Front and Back 100 soiled utility rooms have been flushed to include hopper sprayers. Element #3 Maintenance Technician and EVS supervisor have been re-educated on facility Water Safety and Management plan to include routine flushing and commissioning of portable water systems and Wednesday Water flushing protocols. Element #4 EVS/Designee to complete random weekly audit of required Wednesday flushing to include Spa and soiled utility areas. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for compliance. F880 DSP B Element #1 Residents #1, #29, #52, and #65, have had no adverse outcomes related to observations. Element #2 Residents residing in the facility have potential to be affected. Element #3 Licensed nursing staff have been reeducated on Infection Prevention and Control policy, including hand hygiene, peri care, enhanced barrier precautions, and g-tube care. Infection Control and prevention policy has been reviewed by DON and Administrator and deemed appropriate. All staff were re-educated on hand hygiene and enhanced barrier precautions. Element #4 Don/Designee will complete random weekly audits to ensure appropriate PPE, infection control practices including EBP, hand hygiene, peri care/catheter care, and g-tube care are followed. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. ELEMENT #5 The Administrator is responsible for sustained compliance.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately and completely document advance directives for three residents, leading to potential non-compliance with residents' medical care preferences. Resident #37 was admitted with a DNR order in the physician's orders, but there was no signed paperwork in the resident's chart confirming this status. The social worker was unsure if the resident was informed about the code status, and the resident himself was uncertain about his preference and whether he had signed any related documents. The nursing home administrator confirmed the absence of specific code status paperwork for this resident. Resident #312 had a DNR order, but the required documentation was incomplete. The DNR form was signed by the second advocate instead of the first, and there was no capacity form or two physician signatures to confirm the resident's inability to make decisions. The social worker acknowledged the missing documentation, and the nursing home administrator mentioned efforts to improve the process. Similarly, Resident #60 had a DNR order without signed documentation from the resident and physician. The social worker admitted that hospital discharge paperwork indicating a DNR status could not be used for the facility's DNR order and was unaware of the issue until it was brought to attention.
Plan Of Correction
Element #1: Resident #37, #312, and #60 Advanced Directives have been updated to reflect patient goals of care. Element #2: Residents that currently reside in the facility have potential to be affected. Element #3: Facility Social Workers have been re-educated on Michigan Do-Not-Resuscitate Procedure Act. Advanced Directives of residents currently residing in the facility have been audited; any identified concerns will be corrected in the moment. Element #4: Social Worker/Designee will complete 5 weekly Advanced Directive audits to ensure they meet requirements of the Michigan Do-not-Resuscitate Act and resident goals of care. Variances to be corrected at time of observation. Audits to be submitted to facility QAPI for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Facility Fails to Maintain Clean and Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident #75, who had multiple health conditions including macular degeneration, legal blindness, dementia, diabetes, and kidney disease. Observations revealed that the resident's room contained a mattress on the floor next to the bed, which was heavily soiled with dried liquid stains, dried food, dusty shoe prints, and white dried material. Additionally, the room had significant damage to the walls, including gouges and missing paint, with exposed drywall and metal corner guards. Interviews with facility staff, including a CNA, RN, Housekeeping Manager, and Maintenance personnel, indicated a lack of effective communication and follow-up regarding maintenance and cleanliness issues. The CNA and RN reported that they would inform the nurse or environmental services about such issues, but there was no evidence of work orders being completed. The Housekeeping Manager acknowledged the responsibility for cleaning the mattress, while the Maintenance staff noted that funding for room repairs had not been secured. The maintenance staff also reported that they were the only maintenance personnel present, which may have contributed to the lack of timely repairs and maintenance in the resident's room.
Plan Of Correction
Element# 1 Medical equipment for resident #75 has been cleaned and sanitized. Gouges, dings, and dents on #75 wall have been repaired. Element# 2 Residents residing at the facility have the potential to be affected. All resident mattresses on the floor have been cleaned and sanitized. Facility Maintenance Technician/designee has audited facility resident rooms and work orders were placed for any rooms found with gouges, dings, and dents. Element #3 Environmental services have been educated on mattress cleaning protocol. Facility Maintenance technician has been re-educated on the process to track and retrieve work orders. Element #4 Environmental Services lead or designee(s), will conduct random weekly audits of medical equipment cleanliness and wall integrity. Audits will be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments in a timely manner for two residents, resulting in the potential for inaccurate tracking of discharges. Resident #82 was discharged on 9/19/2024, but her MDS discharge assessment, with an assessment reference date (ARD) of 9/20/2024, was incomplete and not transmitted. The sections GG, J, M, N, O, and P were still in progress. Similarly, Resident #93 was discharged on 9/17/2024, and her MDS discharge assessment, with an ARD of 9/17/2024, was also incomplete and not transmitted, with section K still in progress. During an interview, MDS nurse D confirmed that the discharge assessments for both residents should have been completed and transmitted by specific dates in October 2024.
Plan Of Correction
Element 1: MDS discharge assessment for residents #82 and #93 were completed and transmitted. Element 2: Residents that discharge from the facility have the potential to be affected. The last 6 months of discharges have been reviewed for MDS completion and transmission. Identified concerns were addressed at time of observation. Element 3: MDS Nurses have been re-educated on encoding and transmitting data requirements of CMS. Element 4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct random weekly audits of discharge MDS completion and submission. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II assessment was completed for a resident, resulting in the potential for unmet mental health care needs. The resident, a female with diagnoses including recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder, was admitted to the facility and had a BIMS score indicating severe cognitive impairment. Despite the need for a Level II assessment being identified in the initial PASARR Level I assessment, no Level II assessment was found in the resident's electronic medical record. During an interview, the social worker reported that the PASARR Level I assessment was completed, indicating the need for a Level II assessment. However, the social worker could not produce a paper copy of the Level I assessment and confirmed that there was no completed Level II assessment or recommendation letter available on the OBRA website for the resident. The absence of a PASARR Level II assessment or recommendation letter was confirmed by the survey exit.
Plan Of Correction
Element #1 Resident #16 had a completed PASARR assessment. Resident was assessed for psychosocial well-being and found to be at baseline. Care Plan and Resident Care Summary reviewed and found to be appropriate to reflect resident care needs. Element #2 Residents residing in the facility have the potential to be affected. PASARR assessments for current residents were reviewed for timely completion. Any gaps identified have been addressed. Element #3 The facility Social Workers have been re-educated to the PASARR requirements. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Administrator, or designee(s), will randomly audit residents weekly to validate timely completion of PASARR assessments. The QAPI Committee will review findings and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was receiving Hospice care, resulting in a deficiency. The resident, identified as Resident #58, was admitted with diagnoses including dementia and Alzheimer's disease and had a severely impaired cognitive status. A significant change in the resident's condition was noted, leading to the initiation of Hospice care. However, upon review, it was found that there was no Hospice care plan developed for the resident, which is a requirement for individualized care. During an interview, the MDS nurse revealed a misunderstanding regarding the responsibility for completing the Hospice care plan. The nurse initially believed that the Social Worker was responsible for this task, but later acknowledged that it was her responsibility. The facility's Care Planning and Coordination Policy mandates that each patient must have an individualized written plan of care, which was not adhered to in this case, leading to the potential for unmet care needs for the resident.
Plan Of Correction
Element #1 Residents #58 no longer resides in the facility. Element #2 Residents residing in the facility have the potential to be affected. Resident care plans have been reviewed and updated to reflect current care needs. Element #3 The interdisciplinary team has been re-educated on the Care Planning and Coordination policy. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits of care plans to ensure appropriateness. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, resulting in an unkempt appearance and potential for infection. Resident #52, who was severely cognitively impaired and dependent on staff for activities of daily living (ADLs), was observed multiple times with long, dirty fingernails caked with black debris. Despite the resident's expressed preference for clean and trimmed nails, staff did not provide the necessary care. The care plan indicated that Resident #52 required extensive assistance with ADLs, including nail care. Interviews with staff revealed inconsistencies in the provision of nail care, with some CNAs stating it should be done during showers, while others indicated it could be done anytime. An LPN acknowledged the need for nail care but left the resident's room without completing it, citing time constraints. The Director of Nursing expected nails to be clean and trimmed as needed, but there was no documentation of nail care in the resident's records. This lack of consistent care and documentation contributed to the deficiency identified by surveyors.
Plan Of Correction
Element #1: Nail care was provided for Resident #52. Element #2: Residents' dependent for fingernail grooming/hygiene have the potential to be affected. These Residents who are dependent for fingernail grooming/hygiene will be observed for appropriate fingernail grooming/hygiene and any concerns will be addressed at time of observation. Element #3: Certified Nursing Assistants and Licensed Nurses will be re-educated on ADL standards of care. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will randomly audit dependent residents for ADL standards of care. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Administer Diuretic Medication Leads to Hospitalization
Penalty
Summary
The facility failed to provide care in accordance with physician orders and professional standards for Resident #49, who was admitted with diagnoses including congestive heart failure (CHF) and a pacemaker. Upon admission, the resident's diuretic medication, Lasix, was not administered as ordered, leading to significant weight gain and worsening of his medical condition. Despite the resident's attempts to communicate the need for Lasix to the nursing staff, the medication was not consistently provided, resulting in hospitalization for fluid overload and management of skin breakdowns. The Clinical Nurse Supervisor (CNS) confirmed that the resident's diuretic was listed on hospital paperwork but was not administered regularly. The resident's weight was monitored daily due to CHF, but significant weight increases were not reported to the physician, nor were there any adjustments made to the diuretic medication. The resident's weight increased from 94.2 kg at admission to 106 kg by the time of re-hospitalization, with no documentation of provider notification or intervention. Interviews with the Nurse Practitioner (NP) and review of medical records revealed that the facility's Medical Doctor (MD) had noted the need for continued Lasix, but the medication was not consistently administered. The resident's cardiologist identified the lack of Lasix administration during a pacemaker check, leading to the resident's admission to the hospital for diuresis. The facility's failure to administer Lasix as ordered and to address significant weight changes contributed to the resident's deteriorating condition and subsequent hospitalization.
Plan Of Correction
F684 Element #1: Resident #49 physician orders and treatment reviewed and appropriate. Element #2: Residents that reside in the facility have the potential to be affected. Residents have been reviewed for significant change in condition with physician notification. Element #3: Licensed Nurses have been educated on the facility's Change in Condition Notification of Clinician policy. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits for residents who have significant change in condition physician communication. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk for pressure injuries. Resident #98, who had a history of pressure injuries and was assessed as being at mild risk, was observed multiple times in a wheelchair with improper positioning and without adequate pressure relief. The resident's blue boots, intended to reduce pressure, were often not securely attached, and the resident was left in the same position for extended periods, leading to a pressure ulcer on the right heel. Despite having a catheter, the resident was not repositioned or provided with adequate pressure relief, and catheter care was not performed during an observed transfer. Resident #65, also assessed as being at mild risk for pressure injuries, was observed spending most of his time in a wheelchair without a pressure-reducing cushion, as required by his care plan. The resident was seated on a hoyer sling instead, which does not provide the necessary pressure relief. Staff interviews confirmed the absence of a pressure-reducing cushion, and the resident was observed in the same position for extended periods without repositioning, increasing the risk of skin breakdown. The report highlights the facility's failure to adhere to care plans and professional standards for pressure ulcer prevention, resulting in inadequate care for residents at risk of pressure injuries. The lack of proper positioning, pressure relief, and adherence to care plans for both residents demonstrates a significant deficiency in the facility's care practices, potentially leading to worsening of existing pressure injuries and the development of new ones.
Plan Of Correction
Element# 1 Braden assessment for resident #65, and #98 have been completed, and interventions implemented based on identified risk areas. Element# 2 Residents at risk for skin breakdown have the potential to be affected. Resident Braden assessment identifying residents at risk have been reviewed as well as appropriate interventions in place. Element# 3 Licensed Nurses and CNAs have been educated on Pressure ulcer prevention including repositioning and support surface implementation. Element# 4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s), will conduct weekly observation audits to ensure appropriate skin interventions are in place. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element# 5 The Administrator is responsible for sustained compliance.
Deficiencies in Water Temperature Control and Resident Transfers
Penalty
Summary
The facility was cited for failing to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. During a tour, it was observed that the hot water in the back 100 spa room reached 128°F, despite the presence of a point-of-use mixing valve intended to temper the water to a safe level. Interviews with maintenance staff revealed that the facility did not regularly monitor hot water temperatures to ensure they remained within safe limits, increasing the risk of injury to residents. Additionally, the facility failed to ensure safe chair-to-bed transfers for two residents. One resident, who required substantial assistance for transfers, was observed being transferred by a CNA without the use of a gait belt or assistance from a second staff member, contrary to the resident's care plan. The resident attempted to bear weight on a foot with a pressure wound during the transfer. Another resident, who required a mechanical lift for transfers, was observed being transferred with the hoyer sling improperly attached, risking the resident's safety. Interviews with staff confirmed the improper transfer techniques and the residents' need for specific assistance during transfers.
Plan Of Correction
DPS A Element #1 No residents were mentioned in the citation. Element #2 No residents have been identified at risk. 100 spa rooms are not currently utilized by facility residents. Element #3 Mixing valve in spa room 100 was removed and delimited. Spa room 100 hot water temperature post deliming was under 120 degrees. Facility Maintenance technician has been re-educated on appropriate safe water temperatures in patient care areas. Element #4 Facility Maintenance tech/Designee will complete 5 random weekly temperature checks in resident care areas. Any variances will be addressed at time of observation. Audits to be forwarded to facility QAPI for review and further recommendations. Element #5 The Facility Administrator is responsible for compliance. DPS B Element #1 Resident #98 and #65 have been re-evaluated to determine the amount of assistance needed to transfer safely. Resident care summaries have been updated to reflect current care needs. Element #2 All residents who require assistance with transfers have the potential to be affected by the same deficient practice. Element #3 Licensed nurses and certified nursing assistants have been re-educated on resident care plan/resident care summary regarding the amount of assistance required for a safe transfer and mechanical lift operation. Element #4 Under the direction of the Quality Assurance and Performance Improvement Committee, the Director of Nursing or designee(s) will conduct weekly observation audits of resident transfers including those that use mechanical lifts to assure the correct transfer technique followed. Audits will be forwarded to the Facility QAPI Committee for review and further recommendations. Element #5 The Director of Nursing is responsible for sustained compliance.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper care for two residents with indwelling foley catheters, leading to potential risks of catheter dislodgement, pain, and infection. Resident #98, who was at risk for compromised skin integrity due to impaired mobility and incontinence, was observed without proper catheter securement, causing her pain. The resident had been in her wheelchair for five hours without being toileted, contrary to her care plan, which required toileting every two hours. Additionally, during incontinence care, the catheter was not secured to her leg, and no catheter care was performed, despite the resident's complaints of discomfort. Resident #65, who had a catheter due to bladder outlet obstruction, also did not receive appropriate care. The resident's catheter was not secured with a leg strap as required, and during incontinence care, the CNA did not change gloves after contact with feces, potentially leading to cross-contamination. The CNA also failed to apply barrier cream after cleaning the resident, which is part of standard incontinence care. These deficiencies were observed during staff interviews and direct observations, highlighting lapses in catheter care and infection control practices.
Plan Of Correction
Element #1: For resident #65 and #98, securement devices have been provided per the plan of care. Element #2: Residents residing in the facility receiving assistance with incontinence care and/or have foley catheters have the potential to be affected. Element #3: Licensed nurses and certified nurse assistants will be re-educated to ensure incontinence care and foley catheter care are consistent with professional standards of practice. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will perform randomly weekly audits of dependent residents for appropriate foley catheter care and incontinence care. Weekly audits are to be submitted to the facility QAPI committee for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Monitor Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of oxygen delivery equipment for a resident with chronic obstructive pulmonary disorder (COPD). Resident #16, who was severely cognitively impaired, was observed with an empty water bottle connected to her oxygen concentrator, which was still running. The oxygen tech responsible for maintaining the equipment reported that he was unable to perform the scheduled maintenance the previous week due to scheduling issues, resulting in a delay until the following Monday. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities for monitoring the oxygen equipment. The Registered Nurse (RN) and Clinical Nurse Supervisor (CNS) indicated that nurses should monitor and replace empty water bottles as needed, while the Director of Nursing (DON) stated that she did not expect nurses to monitor the equipment, as an external company was responsible for it. This lack of clarity and oversight led to the deficiency in ensuring the oxygen delivery equipment was properly maintained for Resident #16.
Plan Of Correction
Element #1 Residents #16's oxygen delivery equipment water humidifier bottle has been replaced. Element #2 Residents residing in the facility requiring oxygen therapy have the potential to be affected. Their equipment has been inspected and serviced as identified. Element #3 Licensed nurses were re-educated on oxygen equipment usage and appropriate maintenance of equipment. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will conduct random weekly audits on residents who require oxygen therapy to ensure proper equipment is available and utilized. Element #5 The Administrator is responsible for sustained compliance.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented a review of pharmacy recommendations and follow-up actions for a resident, leading to potential medication side effects and unnecessary medications. The resident, who was cognitively intact, had several pharmacy recommendations that were not addressed by the physician. These recommendations included changing Lidoderm orders to PRN due to frequent refusals, re-evaluating the need for duplicate therapy with Elderberry Immune Complex and Vitamin C, and discontinuing Peri-Colace due to the use of Linzess. Further recommendations included improving glycemic control by adjusting insulin therapy and considering a gradual dose reduction of Zoloft, as required by federal nursing facility regulations. Despite these recommendations, the physician's response was left blank, with no signature or date, indicating a lack of follow-up on the pharmacy's suggestions. The facility's policy required that pharmacists report any irregularities to the attending physician, medical director, and director of nursing, with actions to be taken within specified timeframes. However, the physician did not review or sign the pharmacy recommendations for the resident, and the facility's nurse liaison acknowledged this oversight during an interview. This lack of documentation and follow-up on pharmacy recommendations resulted in a deficiency in medication management for the resident.
Plan Of Correction
Drug Regimen Review Element #1: Resident #15 has not had any negative outcomes related to observation. Resident #15's Pharmacy Recommendations have been reviewed by the facility provider, and new orders have been placed as deemed appropriate by the provider. Element #2: Residents residing in the facility have the potential to be affected. Element #3: The facility provider that is designated to complete Drug Regimen Review has been re-educated on the facility medication management policy. The medication management policy has been reviewed by the Director of Nursing and Administrator and deemed appropriate. Element #4: The Director of Nursing/designee will complete a random monthly audit on the completion of Drug Regimen Review recommendations. Variances will be corrected at the time of observation. Audits will be forwarded to the facility QAPI committee for further review and recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Required Emergency Lighting in Generator ATS Room
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 requirements. During an observation, it was found that there was no battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110, section 7.3. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Technician at the time of discovery. The lack of a battery back-up light in the generator ATS room could potentially affect all occupants of the facility, as it would result in no emergency lighting in the event of a generator failure, leaving no lighted access to emergency equipment. The report does not mention any specific residents or staff affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Maintain Self-Closing Doors in Hazardous Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper protection of hazardous areas as required by Life Safety Code (LSC) 19.3.2.1. Specifically, on two separate occasions, it was found that the doors to the Therapy storage closet and the 100 back hall storage closet (used for emergency food and water storage) did not self-close to a positive latch. These deficiencies were identified during direct observation and confirmed through interviews with the Maintenance Technician present at the time. The report notes that these failures could potentially affect 20 occupants in the event of a fire not being contained to the hazardous area. No information about corrective actions or follow-up measures is included in the report, and there are no details provided about specific residents or their medical conditions at the time of the deficiency.
Smoke Barrier Door Failed to Self-Close Due to Improper Alignment
Penalty
Summary
The facility failed to provide smoke barrier doors that were self-closing or automatic-closing as required by Life Safety Code (LSC) 19.3.7.8 and Chapter 7. During an observation, it was found that the north cross-corridor door leaf at the 100 front hall near room 121 was not plumb, causing it to bind on the floor. This condition prevented the door from releasing upon activation of the fire alarm and from closing sufficiently to maintain the minimum clearance necessary for proper operation in accordance with LSC 7.2.1.8.2. These findings were confirmed during an interview with the Maintenance Technician at the time of discovery.
Inadequate Supervision Leads to Resident's Choking Death
Penalty
Summary
The facility failed to ensure the safety and provide adequate supervision for a resident with a history of dysphagia and choking incidents, resulting in the resident choking on food and subsequently dying. The resident, who had a history of dementia, oropharyngeal dysphagia, and larynx cancer, was on a specialized diet due to his condition. Despite being educated on the risks of not adhering to the recommended diet, the resident chose to eat foods that were not suitable for his condition. The facility did not implement sufficient interventions to ensure his safety while eating, especially when he chose to eat in his room. The resident's care plan indicated that he should eat in communal dining areas for increased supervision, but this was not consistently enforced or documented in the Resident Care Summary. During a COVID-19 outbreak, the main dining room was closed, and the resident was allowed to eat in his room without adequate supervision. Staff members were not fully aware of the resident's need for increased supervision during meals, and there were no additional safety measures in place when he ate alone in his room. On the day of the incident, the resident was found unresponsive in his room after choking on a piece of steak. Despite efforts to resuscitate him, he was declared dead, and the cause of death was determined to be choking. The facility's lack of consistent supervision and failure to implement necessary safety interventions contributed to the resident's death.
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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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