Froh Community Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sturgis, Michigan.
- Location
- 307 N Franks Avenue, Sturgis, Michigan 49091
- CMS Provider Number
- 235345
- Inspections on file
- 20
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Froh Community Home during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen and kitchenette, including peaches, yogurt, milk, and potato chips, were not properly labeled, dated, or discarded according to FDA Food Code requirements. This failure created the potential for foodborne illness among residents consuming food from these areas.
Two residents with histories of trauma and cognitive impairment did not receive required trauma care assessments or individualized care plans. Staff confirmed that trauma assessments were not completed upon admission, and care plans addressing trauma needs were either delayed or missing, despite facility policy requiring trauma screening within 14 days.
Two residents requiring CPAP therapy were found with their respiratory equipment improperly cleaned and stored, with masks left exposed to dust and debris on personal items at the bedside. Staff interviews revealed confusion about cleaning responsibilities, and daily cleaning procedures outlined in physician orders and facility policy were not consistently followed or documented. One resident's care plan also lacked a comprehensive treatment plan for CPAP use.
Staff did not use required PPE, including gowns and gloves, during high-contact care activities for a resident with an MDRO who was under enhanced barrier precautions. Despite care plan orders and facility policy, a CNA was observed making the resident's bed without PPE, and there was confusion among staff regarding the need for precautions and proper signage.
A fire alarm pull box at the activities west exit door was found to be obstructed and not immediately accessible during an observation, in violation of NFPA 70 and NFPA 72 requirements. The Maintenance Director confirmed the finding at the time of the survey.
Surveyors observed missing ceiling tiles in the drop ceiling grid of the wheelchair storage room near the nurse station, which was confirmed by the Maintenance Director. This failure to maintain the ceiling structure could impact the sprinkler system's heat collection process, resulting in noncompliance with NFPA 25 requirements.
Several corridor doors, including those to resident rooms, were unable to close and positively latch due to PPE hangers mounted on top of the doors, preventing them from resisting the passage of smoke as required. This issue was confirmed by the Maintenance Director during surveyor observation and could potentially affect multiple occupants within the smoke compartment.
Surveyors found a hydrocollator machine used for hot pads placed directly on a towel in the therapy area, with the device hot enough to cause burns upon touch. The machine was not installed to prevent ignition of combustibles, as required, and this was confirmed by the Maintenance Director. This deficiency could potentially affect eight occupants in the therapy area.
The facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly as required. The DON could not provide documentation for QAA meetings from September 2023 to January 2024, and the ADON confirmed a canceled meeting in November 2023 that was not rescheduled.
The facility failed to ensure proper infection control protocols, including Enhanced Barrier Precautions (EBP) and hand hygiene, for several residents with wounds, catheters, and infections. Staff did not don PPE, clean equipment, or perform hand hygiene, increasing the risk of infection spread and cross-contamination.
The facility failed to offer the updated pneumococcal vaccines to four residents, resulting in a delay in their opportunity to receive or decline the vaccination. The Infection Preventionist was unaware of the changes to the immunization requirements, leading to the oversight.
The facility failed to preserve resident dignity during meal service, leaving three residents who required assistance with eating to wait up to 40 minutes while others around them were served and consumed their meals. Staff interviews confirmed that the dining room service process led to these residents being served last, causing them to watch their tablemates eat while they waited.
The facility failed to provide a written notice of transfer for a resident hospitalized due to a myocardial infarction, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. Staff interviews revealed a lack of awareness and adherence to the policy requiring a transfer notice.
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews for a resident with vascular dementia, insomnia, and chronic pain. Despite the care plan indicating the need for pharmacy consultant reviews, no reviews were found in the resident's medical record for several months, as confirmed by the Director of Nursing.
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use. The resident was prescribed lorazepam 0.5 mg PRN for anxiety with no end date, contrary to the requirement that PRN psychotropic medications be limited to 14 days. No gradual dose reductions (GDRs) were attempted, and the lack of auditing led to incomplete monitoring of the medication's use and potential adverse reactions.
Failure to Label, Date, and Discard Food Items per FDA Food Code
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items in both the main kitchen and a kitchenette, as observed during multiple tours. In the walk-in refrigerator, a large plastic container of peaches was found without any label or date. Additionally, a plastic container of yogurt and an open half-gallon jug of 2% milk were found with open dates of 5/17 and expiration dates of 5/19, while another open half-gallon jug of 2% milk lacked any label or date. In the kitchenette by Maple and Oak Halls, an open bag of potato chips was observed to be unsealed and without a label or date. These findings were confirmed during observations with the Certified Dietary Manager, Chef Manager, and Food Service Regional Director of Operations. The lack of proper labeling, dating, and discarding of food items is not in accordance with the 2022 FDA Food Code, which requires ready-to-eat, time/temperature control for safety foods to be clearly marked with the date by which they must be consumed, sold, or discarded. The failure to follow these standards created the potential for foodborne illness among all residents consuming food from the kitchen.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to complete trauma care assessments and develop corresponding care plans for two residents with known histories of trauma. Both residents were identified on the facility matrix as having PTSD or trauma, and their Minimum Data Set (MDS) assessments indicated cognitive impairment, anxiety, and depression. For one resident, the care plan addressing psychosocial well-being was created several months after admission, and no trauma assessment was found in the medical record. The social services staff confirmed that no trauma assessment had been completed for this resident, despite being aware of her trauma history. For the second resident, the MDS showed she was not cognitively intact and had diagnoses of anxiety and depression. The resident's guardian reported that trauma was not indicated in the facility's referral, and the social services staff acknowledged that no formal trauma assessment was completed upon admission. The Director of Nursing confirmed that trauma assessments should be completed within 14 days of admission and that neither resident had a trauma assessment or a starting point for treatment documented in their records. Facility policy requires trauma screening within 14 days of admission, but this was not followed for these residents.
Failure to Ensure Proper Cleaning and Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for two residents who required CPAP therapy. One resident, who was cognitively intact and had a history of heart failure and pneumonia, was observed multiple times with a CPAP mask left unprotected on personal items at the bedside, exposed to dust and debris. The resident expressed concern about the cleanliness of the mask and stated that staff assisted with mask removal but was unsure if it was cleaned as required. Staff interviews revealed confusion about cleaning responsibilities, and review of physician orders and care plans confirmed that daily cleaning was required but not consistently performed or documented. Another resident, who was cognitively impaired with diagnoses including dementia, partial paralysis, and Parkinson's disease, was also observed with a CPAP mask covered by a fabric but still left on personal items and exposed to dust and debris. The mask was sometimes covered with a stuffed animal on top. Staff interviews and policy review indicated that the mask should be cleaned daily and protected, with fabric coverings switched out daily due to the resident's skin sensitivity. However, observations showed that these procedures were not consistently followed, and the resident's care plan did not include a comprehensive treatment plan for CPAP use.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use required personal protective equipment (PPE), specifically gowns and gloves, during high-contact care activities for a resident who was under enhanced barrier precautions (EBP) due to a multidrug-resistant organism (MDRO). The resident, a male with severe cognitive impairment and multiple diagnoses including candidal sepsis and diverticulitis with perforation, had physician orders and a care plan in place requiring EBP for high-contact activities such as dressing, bathing, transferring, and changing linens. On one occasion, a CNA was observed making the resident's bed without wearing any PPE, despite the care plan and facility policy specifying that gown and gloves should be used during such activities. Further review revealed inconsistencies in the availability and signage of PPE for the resident. Initially, no signage or PPE was present in or outside the resident's room, but later signage and a PPE supply bin were observed. The CNA involved stated that PPE was only necessary for residents in isolation and believed the resident was no longer under such precautions, indicating a lack of understanding of EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was still under EBP and that staff were expected to use PPE during high-contact care, including linen changes.
Obstructed Fire Alarm Pull Box at Activities West Exit
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program as required by NFPA 70 and NFPA 72. During an observation, it was found that the fire alarm pull box located at the activities west exit door was obstructed and could not be immediately accessed. This issue was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Obstructions in front of the Activities fire alarm pull box have been removed. All other pull stations have been inspected and none are obstructed. All pull-station areas will be inspected on a weekly basis by the maintenance department to make sure there are no obstructions preventing access to the pull stations. All Department Managers and Maintenance staff will be inserviced on keeping pull stations free from obstructions. The Maintenance Director will monitor compliance by completing rounds weekly, observing for obstructed pull stations.
Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain and test the automatic sprinkler system in accordance with NFPA 25 requirements. During an observation, surveyors found missing ceiling tiles in the drop ceiling grid within the wheelchair storage room near the nurse station. This deficiency was confirmed through an interview with the Maintenance Director at the time of observation. The absence of ceiling tiles could interfere with the sprinkler system's heat collection process, as required by NFPA 25, 5.2.1. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The ceiling tiles in the wheelchair storage room have been installed. All other areas of the building have been inspected, and no other ceiling tiles are missing. Ceiling tiles will be inspected on a weekly basis by the maintenance department and documented in the preventative maintenance log. The Maintenance Director will monitor compliance by completing rounds weekly, observing for missing ceiling tiles.
Corridor Doors Blocked by PPE Hangers Preventing Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors protecting corridor openings were able to resist the passage of smoke as required by NFPA 19.3.6.3. During observations, it was found that several resident room doors, specifically room #3 in cottonwood hall and rooms #44 and #4 in maple hall, did not close and positively latch. The deficiency was directly caused by personal protective equipment (PPE) hangers that were mounted on the top of these doors, which physically prevented the doors from closing and latching as required. These findings were confirmed during interviews with the facility Maintenance Director at the time of observation. The report notes that this issue could potentially affect 24 occupants within the smoke compartment if the doors fail to prevent the passage of smoke during a fire. The deficiency was identified through direct observation and interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Maintenance removed all over the door hangers and mounted PPE holders with a different method so as not to impede door from having a positive latch. All other doors have been inspected to ensure that no obstructions keep the doors from latching. The maintenance staff will check doors weekly and document checks in the preventative maintenance log. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for door latching issues.
Improper Placement of Hydrocollator Machine Creates Fire Hazard
Penalty
Summary
A deficiency was identified when surveyors observed a hydrocollator machine, used for hot pads, placed on top of a towel in the therapy area. The machine was found to be hot enough to cause a heat burn upon contact, and it was not installed in a manner that would prevent combustible materials from being ignited, as required by code 19.5.2.2. The observation was confirmed by the facility Maintenance Director at the time of the survey. This situation could potentially affect eight occupants within the therapy area if ordinary combustibles come into contact with the heat source.
Plan Of Correction
Hydrocollator was removed from the shelf and towel location and installed on a metal shelf. All other heat producing equipment has been reviewed to ensure that combustible items are not touching them. Department Managers and Maintenance staff will be inserviced on the safe use of heat producing equipment. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for combustible materials are keep away from heat producing equipment.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly, as required. During an interview, the Director of Nursing (DON) presented a QAA binder with meeting sign-in sheets and notes dated February, March, and April 2024, indicating that the facility had changed QAA meetings from quarterly to monthly starting in February 2024. However, the DON was unable to locate the quarterly sign-in sheets from September 2023 to January 2024 to confirm whether QAA meetings were held during that period and who attended. Additionally, the Assistant Director of Nursing (ADON) mentioned that a QAA meeting scheduled for November 2023 was canceled and was unsure if it was rescheduled. The facility's QAPI policy requires QAA meetings to be held at least quarterly, but there was no documentation to verify compliance with this requirement for the specified period.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, including Enhanced Barrier Precautions (EBP) and transmission-based precautions, for several residents. For instance, Resident #31, who had a suprapubic catheter, did not have any EBP signage or personal protective equipment (PPE) available for staff. Similarly, Resident #50, who had a Foley catheter, also lacked EBP signage and PPE. Resident #27, with a pressure ulcer and a Foley catheter, did not have EBP signage, and staff did not don PPE before performing wound care. Additionally, Resident #261, who had a urinary tract infection with a multidrug-resistant organism, did not have contact precautions in place, and staff entered the room without PPE. Resident #262, with multiple wounds and cellulitis, and Resident #5, with pressure ulcers, also lacked EBP signage and PPE in their rooms. The Infection Preventionist (IFP) was unaware of the updated guidance for implementing EBP for residents with wounds, pressure ulcers, and indwelling devices. The facility also failed to ensure adequate hand hygiene and hygienic wound care. For example, CNA F did not clean the Hoyer lift after transferring Resident #5, and CNA E did not perform hand hygiene after handling soiled linen and taking a drink from a personal beverage cup in the spa room. Additionally, Wound Nurse Z did not turn off a pedestal fan blowing air directly at Resident #5's feet during a dressing change, which disturbed the dressing supplies. These deficiencies resulted in an increased potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents. The facility's failure to implement proper infection control measures, including EBP and hand hygiene, compromised the safety and well-being of the residents.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four residents, resulting in a delay in the residents being given the opportunity to receive or decline the vaccination. Resident #26, a female with diagnoses including heart failure, diabetes, and dementia, had previously received PCV13 and PPSV23 but was not offered the updated PCV15 or PCV20 vaccine. The Infection Preventionist (IFP) was unaware of the changes to the immunization requirements. Similarly, Resident #50, a male with conditions such as acute kidney failure and diabetes, had also received PCV13 and PPSV23 but was not offered the updated vaccines. The IFP confirmed that this resident should have been offered the PCV15 or PCV20 vaccine as well. Resident #38, a female with dementia and Parkinson's disease, had received a pneumococcal vaccine at an unknown outside setting and should have been offered the updated vaccines according to the IFP. Resident #24, a female with diagnoses including diabetes and leukemia, had also received a vaccine from an outside provider, but this was not documented in the medical record. The IFP reported that this resident should have been offered the PCV15 or PCV20 vaccine and then PPSV23 one year later. The CDC guidelines indicate that adults who have previously received PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, or if their vaccination history is unknown, they should receive one dose of PCV15 or PCV20.
Failure to Preserve Resident Dignity During Meal Service
Penalty
Summary
The facility failed to preserve resident dignity during meal service in the dining room for three residents who required assistance with eating. Observations revealed that these residents were seated with drinks and desserts in front of them but were unable to consume them without assistance. They were left waiting for up to 40 minutes while other residents around them were served and consumed their meals. This resulted in the residents being unable to eat or drink independently for an extended period, which could lead to feelings of embarrassment and shame. Interviews with staff members indicated that the dining room service process involved serving hall trays first, followed by residents needing some assistance, then independent residents, and finally those requiring full assistance. This process led to the residents who needed direct assistance being served last, causing them to watch their tablemates eat while they waited. The Director of Nursing and Assistant Director of Nursing acknowledged that residents should not be left waiting to be served while others at their table are eating, indicating a recognition of the issue but no immediate corrective action was mentioned in the report.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was discharged to the hospital due to a myocardial infarction and returned to the facility after a week. During an interview, the resident could not recall receiving a written transfer notice. A review of the resident's chart and the December 2023 Transfer Log confirmed that no written notice of transfer was provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and a Financial Assistant, revealed a lack of awareness and adherence to the policy requiring a transfer notice. The Director of Nursing presented paperwork sent with residents to the hospital, which did not include a transfer/discharge notice. The Financial Assistant admitted that transfer/discharge notices had not been given to residents or their responsible parties for a long time, especially if the resident wanted to go to the hospital. The facility's Discharge Planning Policy indicated that the Business Office should provide notice of transfer or discharge within 24 hours or as soon as practicable in emergency situations, but this was not followed in the case of the resident in question.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for one resident reviewed for unnecessary medication use. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was mildly cognitively impaired with a BIMS score of 11 out of 15. The resident had a physician's order for lorazepam to be taken as needed up to four times a day. Despite the care plan indicating the need for pharmacy consultant reviews, no monthly medication regimen reviews were found in the resident's medical record from January 2024 to April 2024. This was confirmed by the Director of Nursing, who reported that no reviews had been completed during this period.
Failure to Limit PRN Psychotropic Medication and Implement GDRs
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use, specifically in the case of Resident #28. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was prescribed lorazepam 0.5 mg PRN for anxiety with no end date. The care plan indicated that the resident should be prescribed the lowest effective dose and that the resident's mood and response to the medication should be observed. However, the PRN order for lorazepam was not limited to 14 days as required for psychotropic medications, and no gradual dose reductions (GDRs) were attempted for the resident's PRN use of lorazepam. Interviews with the RN and DON confirmed that the PRN order was open-ended and that no GDRs had been completed for Resident #28. The Director of Nursing (DON) reported that new medication orders were reviewed by the clinical team in daily meetings and all medications were reviewed weekly, but no audits were completed on original orders. This lack of auditing and failure to implement GDRs or limit the PRN order to 14 days resulted in incomplete monitoring of the use, potential adverse reactions, and dosage adjustments of the psychotropic medication for Resident #28.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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