Greentree Of Hubbell Rehabilitation And Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Hubbell, Michigan.
- Location
- 52225 B Avenue, Hubbell, Michigan 49934
- CMS Provider Number
- 235551
- Inspections on file
- 26
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Greentree Of Hubbell Rehabilitation And Health during CMS and state inspections, most recent first.
The facility failed to ensure adequate weekend CNA staffing to meet resident needs, as shown by CMS PBJ data indicating excessively low weekend staffing and by internal schedules and payroll records reviewed with the COO. On multiple weekend day and afternoon shifts, only 3 to 3.5 CNAs were scheduled, which did not meet the facility’s own Facility Assessment requirement of at least 4–5 CNAs on day shift and 4 CNAs on afternoon shift. This deficiency, occurring under CMS rules that require staffing to be determined by the facility assessment, had the potential to affect all residents’ physical, mental, and psychosocial well-being.
The facility did not complete required annual performance reviews for five CNAs, as confirmed by personnel record review and interviews with the BOM and DON. Staff files for CNAs hired over multiple years lacked any documented evaluations, despite the expectation that reviews be conducted annually. The facility was unable to provide a performance review policy, and this failure created the potential for inadequate care and unmet needs for all residents.
A resident with colon cancer and severe cognitive impairment had an order for scheduled hydrocodone-acetaminophen, but 120 tablets of this Schedule II narcotic were found to be missing when staff attempted to administer a dose. Internal review showed the medication had not been administered, destroyed, or documented as wasted, and chain-of-custody records did not account for its disposition. At the time, pharmacy medications, including controlled drugs, were delivered in unsecured cardboard boxes via common carriers, often left unattended in the front office among other packages, and opened by nursing staff without tamper-evident safeguards. Facility policies on pharmacy services and medication storage did not describe the actual delivery process, did not specify who was responsible for receiving and inspecting shipments for tampering, and did not address the handling of courier-delivered medications, contributing to the misappropriation of the resident’s narcotic pain medication.
Surveyors found that the facility failed to maintain a clean, homelike, and odor-free environment, with strong urine odors noted at the entrance, in hallways, on both A and B units, and in multiple resident rooms and nursing station areas. Several resident rooms had heavily soiled privacy curtains and bathrooms with dried urine buildup and smeared feces on and around toilets, along with strong urine odors. A bathroom door was also observed with a large area of chipped paint. A housekeeper reported that resident room and bathroom floors are not mopped daily and that soiled linens and briefs are sometimes not promptly removed, especially on weekends when staffing is limited.
Surveyors found that multiple CNAs had not received the required 12 hours of annual in‑service training, despite facility policy stating that each nurse aide must complete at least 12 hours of training per year based on their hire date. Review of training records showed several CNAs with no documented training for extended periods after hire, and the DON acknowledged that these staff did not meet the annual training requirement.
A cognitively severely impaired resident with colon cancer had an order for scheduled Hydrocodone-Acetaminophen, but during a routine med pass staff discovered the narcotic supply was missing. Pharmacy records indicated 120 tablets should have been on hand, yet review of proof-of-use sheets and shift counts showed no documentation of administration, destruction, or waste. Staff interviews revealed that pharmacy medications were delivered in unsecured cardboard boxes left among other packages in the front office, without consistent signing or verification, and that the entire inventory sheet, narcotic count sheets, and four 30-tablet packages of the drug were missing. The facility’s abuse, neglect, and exploitation policy referenced preventing misappropriation of resident property but did not include specific protocol for misappropriation under F602.
Surveyors found that two CNAs did not have any documented initial or annual competency evaluations or skills demonstrations in their personnel files, despite facility policy requiring competency assessment during orientation and annually thereafter. A manager confirmed that staff are expected to have yearly competency training, but these two CNAs’ records lacked any such documentation.
A resident with dementia, dysphagia, chronic kidney disease, and recent treatment for walking pneumonia experienced a drop in SpO2 to 82% during a breathing treatment. An RN applied supplemental O2 under standing orders but did not document repeat vitals, follow-up SpO2, or the use of an oxygen mask, and began O2 without a specific physician order beyond standing orders. Later, an LPN documented that the resident’s O2 saturation dropped with O2 titration, along with decreased appetite, weakness, and increased sleep, and the resident requested hospital transfer, which was ordered by the MD. The EMR showed an order for O2 at 8 L/min via nasal cannula but no repeat vitals after the change in condition. The DON reported that standing orders allowed only up to 2 L O2 without an MD order and that titration required physician direction, while facility policies required physician notification for SpO2 below 89% and for significant changes in condition.
A resident with dementia, dysphagia, and chronic kidney disease developed a congested cough, bilateral rhonchi, and weakness, but was not tested for COVID-19 despite existing PRN orders for SARS-CoV-2 testing and facility policy requiring testing of anyone with even mild COVID-19 symptoms. The ADON/IP stated that symptomatic residents should be tested and acknowledged that testing "slipped" their mind because the resident was being treated for pneumonia. This inaction conflicted with the facility’s Infection Prevention and Control Program and CDC guidance to test residents and HCP with new respiratory illness signs or symptoms.
Two residents with cognitive impairments and special dietary needs were inadequately supervised, resulting in one resident repeatedly accessing and eating discarded food not suitable for her diet, and another sustaining serious burns from hot coffee served without a lid. Staff interviews and documentation revealed persistent staffing shortages, leading to lapses in supervision and failure to follow dietary orders.
The facility did not provide enough nursing staff to meet resident needs, resulting in missed hygiene and grooming, lack of supervision for residents at risk of choking, extended call light wait times, and a severe burn injury to a resident. Staff reported frequent mandatory overtime, burnout, and an inability to complete care tasks, which directly contributed to these deficiencies.
Multiple residents were observed with poor personal hygiene, including soiled clothing, dirty fingernails, and matted hair, while staff interviews revealed that chronic understaffing and frequent mandatory overtime led to rushed care and missed hygiene tasks. Residents reported long wait times for assistance and sometimes refused care due to staff being rushed or perceived as rude. Facility policies required maintaining resident dignity, but these standards were not met due to insufficient staffing.
The facility failed to adhere to food safety standards, risking foodborne illness for 53 residents. An uncovered ice container was left unattended, hamburger patties were improperly reheated, and sanitizing solutions were inaccurately tested. Staff lacked knowledge of proper procedures, violating FDA Food Code 2017.
The facility failed to maintain a safe and sanitary environment, affecting all 53 residents. An exit door had a gap allowing cold air and vermin entry, and a shower room wall had missing tiles with sharp edges. In the kitchen, a vacuum breaker was defective, risking contamination of the water supply.
The facility failed to ensure accurate and timely completion of advance directives for four residents. One resident's Code Status form was improperly witnessed before the legal guardian's signature, another resident's previous form was missing, and a third resident did not have a directive completed upon admission. Additionally, a fourth resident's documentation lacked the required witness signatures. These deficiencies were identified through interviews and record reviews, contrary to the facility's policy of quarterly review.
The facility failed to maintain a sanitary and homelike environment, as evidenced by persistent odors of urine and feces and inadequate room aesthetics. Strong odors were noted near the Hall B nurses' station and other areas, with staff unable to identify the source. Additionally, window draperies were improperly fastened, and cork bulletin boards were insecurely attached in residents' rooms. Maintenance issues were not documented, leading to delays in addressing these deficiencies.
The facility failed to ensure staff in food and nutrition services had the necessary skills, leading to potential unsafe practices. The Kitchen Manager (KM) A and another staff member were unable to demonstrate proper sanitizing procedures, and KM A had not completed the required Certified Dietary Manager program, holding only a Certified Food Manager credential.
The facility failed to provide meals at a palatable temperature and in a consumable form for several residents. Observations showed that food was served cold from un-insulated carts, and residents expressed dissatisfaction with the quality and temperature of their meals. One resident, unable to peel a hard-boiled egg due to arthritis, received no assistance, highlighting a lack of consideration for residents' needs.
A facility failed to obtain consent for psychotropic medications for a resident with severe cognitive impairment. The resident was prescribed quetiapine fumarate and sertraline without prior consent from the guardian, who reported a lack of communication from the facility. Interviews revealed that obtaining consents for mood-altering medications was a known issue, and verbal consent was obtained long after the medications were initiated.
A facility failed to conduct quarterly care conferences and notify the responsible party for a resident with severe cognitive impairment. The resident's guardian was only involved in two care conferences since admission, with significant gaps between meetings. Staff confirmed the absence of a regular care conference process under previous administration, contrary to facility policy requiring quarterly reviews.
A facility failed to conduct the required quarterly assessments for a resident self-administering medication, despite the resident having intact cognition and a diagnosis of peripheral vascular disease. The last assessment was documented months prior, and interviews with staff confirmed the oversight. Facility policy required quarterly reassessments, which were not completed, leading to the resident self-administering medication without appropriate evaluations.
Two residents experienced discomfort and dissatisfaction due to inappropriate incontinence briefs provided by the facility. One resident was given briefs that were too small, while another preferred a different style that was not available. The ADON acknowledged the need for accurate sizing and respecting resident preferences, and the NHA was informed of the deficiency.
A facility failed to obtain written authorization before withdrawing $500 from a resident's trust fund, intended for personal use, and applied it to the facility bill. The resident, with severe cognitive impairment, had a guardian who reported the unauthorized transaction. The Business Office Manager admitted to receiving verbal consent but did not provide a receipt or written documentation, contrary to facility policy.
A facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, despite requests from their guardian. The facility had recently switched to using their own EMR system for managing resident fund accounts, and the BOM noted that the previous management service did not allow access to verify if statements were sent. The NHA planned to contact the management service to confirm the status of the statements, but none were provided by the survey exit.
The facility failed to provide timely 48-hour notices of Medicare benefit termination for three residents, preventing them from appealing non-coverage decisions. A resident with severe cognitive impairment did not receive any notification, while two others received notices only one day before coverage ended, contrary to the facility's policy requiring a two-day notice.
A facility failed to provide a resident and their representative with written notification of transfer reasons before hospitalizations. The resident, with intact cognition, was hospitalized three times due to medical emergencies, but no transfer notices were documented. The Social Services Designee was unfamiliar with the notification process, indicating a deficiency in policy adherence.
A resident with dementia, diabetes, hypertension, and anemia experienced multiple falls over several months. Despite these incidents, the facility failed to revise the resident's care plan after each fall, contrary to their policy on incidents and accidents, which requires immediate interventions and corrective actions to prevent recurrences.
The facility failed to maintain infection control and implement effective pressure ulcer prevention for three residents. An LPN contaminated wound supplies by using a personal cell phone without changing gloves. A resident's heels were not properly elevated, and another developed a Stage 2 pressure ulcer due to lack of timely pressure redistribution measures. The facility did not follow its own policies, leading to these deficiencies.
A resident with intact cognition and multiple diagnoses sustained a burn injury while smoking, which was not investigated by the facility. The resident reported burning himself when smoking cigarettes down to the filter, and staff failed to notice. The facility did not document or investigate the incident, contrary to their policy requiring such actions for resident injuries.
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents with cognitive impairments and mental health conditions. Medications were administered without proper consent or documentation, and required assessments were not conducted as per facility policy.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during insulin administration for a resident. Errors included not disinfecting the insulin pen hub and failing to prime the pen properly, leading to potential inaccurate dosing. The RN acknowledged the mistakes, and the ADON confirmed the errors, which were against the instructions for proper insulin pen use.
The facility failed to perform pre-employment and pre-admission TB screenings for several newly hired staff and recently admitted residents, as required by CDC guidelines. The Nursing Home Administrator confirmed the lapse in infection control practices, resulting in the potential for TB exposure and transmission.
A visually impaired resident was repeatedly unable to locate her call light, which was found out of reach on multiple occasions. The resident expressed frustration and helplessness, and staff confirmed the call light was not properly secured near her. The DON acknowledged that call lights should always be accessible, especially for residents with severe visual impairments.
The facility failed to ensure privacy and dignified treatment for two residents. One resident was left exposed during incontinence care, while another was fully visible from the hallway while sitting on the toilet. The Director of Nursing confirmed that residents should be cared for in a manner that preserves their dignity.
The facility failed to maintain safe and clean resident rooms for two residents. One resident's mattress was on the floor without proper coverings, and the floor was visibly soiled. The mattress and fall mat protruded into another resident's space, causing difficulty in maneuvering a wheelchair. Additionally, the room had an uncovered utility box and wall damage.
The facility failed to ensure safe transfers for two residents, both of whom were transferred without the use of gait belts as required by their care plans. This resulted in the potential for falls and injury, with staff not adhering to standard practices or checking care plans for transfer needs.
Inadequate Weekend CNA Staffing Below Facility Assessment Requirements
Penalty
Summary
The facility failed to provide adequate nursing staff on weekends to meet resident needs and to comply with its own Facility Assessment (FA) and CMS requirements, potentially affecting all 44 residents. CMS Payroll Based Journal (PBJ) staffing data for fiscal year quarter 4 of 2025 showed the facility triggered for excessively low weekend staffing. During an interview and record review, the Chief Operating Officer (COO) confirmed that weekend schedules and payroll records revealed low Certified Nurse Aide (CNA) staffing on specific weekend dates and shifts, including day and afternoon shifts staffed with only 3 to 3.5 CNAs. These staffing levels were below the FA, last updated 2/1/25, which specified a minimum of 4–5 CNAs on day shift and a minimum of 4 CNAs on afternoon shift. The deficiency occurred in the context of a CMS final rule, effective 8/8/24, requiring that facility assessments directly inform and determine staffing requirements. The report does not identify specific residents by condition or medical history but states that the inadequate staffing had the potential to affect all 44 residents residing in the facility, in terms of their physical, mental, and psychosocial well-being.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for all five reviewed CNAs, creating a deficiency in monitoring and evaluating staff performance. Personnel record review showed that one CNA hired in November 2021, one CNA hired in February 2023, one CNA hired in July 2023, one CNA hired in November 2023, and one CNA hired in January 2024 each had no documented performance review completed at least every 12 months. The Business Office Manager stated there were no evaluations for any of these five staff members and acknowledged that evaluations were supposed to be done annually. The DON also acknowledged that annual performance reviews had not been completed. The facility did not provide a policy regarding performance reviews prior to exit. This deficient practice resulted in the potential for inadequate care and unmet care needs for all 44 residents residing in the facility. All 44 residents in the facility were identified as being potentially affected by the lack of annual performance reviews for the CNAs, but no specific resident medical histories or conditions at the time of the deficiency were described in the report.
Misappropriation of Controlled Pain Medication Due to Inadequate Delivery and Storage Controls
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its own policies for the delivery, receipt, and secure storage of controlled medications, resulting in the misappropriation of 120 hydrocodone-acetaminophen tablets prescribed for Resident #51. Resident #51 was originally admitted on 8/6/2024 with diagnoses including colon cancer and had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet three times daily. A Minimum Data Set dated 10/24/2025 documented a BIMS score of 9/15, indicating severe cognitive impairment. On 9/19/2025, during a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic pain medication was missing when they attempted to obtain it from the StatSafe and were informed by the pharmacy that the facility should already have 120 tablets on hand. The facility’s internal investigation determined that the hydrocodone tablets for Resident #51 had not been administered, destroyed, or documented as wasted and were unaccounted for. Review of proof-of-use sheets, shift counts, and chain of custody records showed no documentation explaining the disposition of the medication. A nurse was identified as potentially involved in the missing medication based on the chain of custody review, and that nurse was no longer employed at the facility as of 9/14/2025. The incident was reported as misappropriation of 120 narcotic pain medications for Resident #51. Interviews and observations revealed that, at the time of the incident, pharmacy medications, including controlled substances, were delivered to the facility in regular cardboard boxes sealed with standard packaging tape, without locks or tamper-evident features. Nurses reported that these boxes were often left unattended in the front office among other facility and resident packages, and a nurse would have to search through multiple boxes to locate the pharmacy shipment. A single nurse would open the box, check inventory, and fill the medication cart with routine medications, and later call another nurse to sign off on the narcotic inventory sheet, even though the box itself could be easily opened and re-taped, including from the bottom. Staff interviews indicated that there was no clear, written procedure in the facility’s Pharmacy Services or Medication Storage policies describing who was responsible for receiving delivered medications, checking the box for tampering, or ensuring secure handling upon delivery. Policy review confirmed that, although the policies addressed storage and reconciliation of controlled substances, they did not address the actual delivery process or current courier methods, contributing to the conditions under which the controlled medications for Resident #51 were misappropriated. Additional staff interviews further supported that the delivery process lacked defined safeguards. RN B and RN C both described that pharmacy boxes arrived via UPS or FedEx, were not locked, and could be opened and re-taped without detection. They acknowledged that, even after the missing narcotic incident, pharmacy boxes sometimes continued to be retrieved from the front office among other packages, and there was uncertainty about who was responsible for inspecting boxes for signs of tampering. Observation of a pharmacy-labeled box delivered by UPS showed it to be a standard cardboard box with packaging tape and no locking or tamper-proof features. The Assistant DON confirmed that the facility’s policies did not specify the current procedures for receiving medications, did not address how medications were delivered, and did not identify who was responsible for checking in delivered medications or inspecting for tampering, which were key process gaps associated with the misappropriation of Resident #51’s controlled medication supply.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike, clean, and odor-free environment for all residents, staff, and visitors. On multiple observations over several days, surveyors noted a strong odor of urine upon entering the facility, in the hallways leading to the A and B units, and throughout the nursing station areas. Strong urine odors were repeatedly documented on both units, including the back unit rooms 1–20 and the unit with rooms 21–31, as well as during environmental inspections and resident pool observations. Individual resident rooms were also affected, with some rooms having a strong urine odor when toured by the surveyor. In addition to pervasive odors, surveyors observed visibly soiled environmental surfaces. Privacy curtains in at least two rooms were heavily soiled with brown smudge marks in multiple areas. Bathrooms in at least two rooms had dried urine buildup around the toilet seat, seat fasteners, and base, and dried feces smeared on the toilet tank, rim of the toilet seat, and underneath the toilet seat on the tank bowl, with strong urine odors present. A bathroom door in another room had a large area of chipped paint greater than 12 inches in diameter. A housekeeper reported that resident room and bathroom floors are not mopped daily and attributed the strong urine smell to infrequent mopping, soiled linens, and soiled briefs not being promptly removed to the off-site laundry and garbage building, particularly on weekends when the facility is short staffed.
Failure to Provide Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that CNAs received at least 12 hours of annual in‑service training as required by its Nurse Aide Training Program policy. During an interview, the Business Office Manager (BOM) stated that the annual 12-hour CNA training requirement is based on each CNA’s hire date. Facility documents reviewed showed that CNA E, hired on 11/10/21, had 0 hours of training since 5/28/24; CNA K, hired on 11/10/23, had 0 hours of training since 11/10/23; CNA L, hired on 1/15/24, had 0 hours of training since hire; CNA M, hired on 7/13/23, had 0 hours of training since hire; and CNA N, hired on 2/24/23, had 0 hours of training since 11/15/23. In a subsequent interview, the DON acknowledged that these five CNAs did not have the required 12 hours of annual training, despite the written policy stating that each nurse aide shall be provided at least 12 hours of in‑service training annually based on their employment date. No specific residents, medical histories, or resident conditions were described in relation to this deficiency, and the report focused solely on staff training records and staff interviews.
Misappropriation of Resident Narcotic Medication Due to Inadequate Control of Pharmacy Deliveries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically a controlled pain medication, from misappropriation. A cognitively severely impaired resident with colon cancer was admitted with an order for Hydrocodone-Acetaminophen 10-325 mg, one tablet three times daily. During a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic medication was missing and contacted the pharmacy to obtain a refill. The pharmacy reported that the facility should already have 120 tablets of the medication on hand, prompting a review of medication records and counts. Review of proof-of-use sheets and shift narcotic counts showed that the 120 tablets of Hydrocodone-Acetaminophen had not been administered, destroyed, or documented as wasted and were unaccounted for. Chain-of-custody review identified a nurse as potentially involved in the missing medication, and this nurse was no longer employed at the facility as of several days prior to the discovery. Interviews with nursing staff indicated that the medication was likely taken by a staff member when the pharmacy shipment was delivered, and that the nurse in question had not been signing for the pharmacy medication box upon delivery. Further interviews revealed that the pharmacy medication boxes arrived as regular cardboard packages taped with packaging tape, without locks or tamper-proof features, and were sometimes left in the front office among other delivered packages. Staff reported that it would have been easy for anyone, including staff or delivery personnel, to open and retape the boxes, and that in this case the entire inventory list, four narcotic count sheets totaling 120 pills, and four packages of 30 pills each were missing from the box. The facility’s Abuse, Neglect and Exploitation policy stated that the facility would prohibit and prevent misappropriation of resident property, but the policy did not address or reference the State Operations Manual or protocol specific to misappropriation (F602).
Missing Initial and Annual Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two CNAs had the required initial and annual competency evaluations and documented skills demonstrations as required by facility policy. Review of personnel records showed that one CNA hired on 1/15/24 had no dated competency skills documented in the file from the date of hire onward, and another CNA hired on 2/24/23 likewise had no dated competency skills documented since hire. During an interview, the Business Office Manager confirmed that two CNAs did not have competency trainings in their personnel files, despite the expectation that staff receive annual competency training. The facility’s written Competency Evaluation policy, last reviewed/revised on 1/1/25, states that each employee is to be evaluated to assure appropriate competencies and skills for their job, with initial competency evaluated during orientation and subsequent or annual competency evaluated thereafter, but these evaluations were not documented for the two CNAs. No resident-specific information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Monitor and Notify Physician After Resident’s Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and notify a physician of a change in condition for one resident and to document follow-up assessments after initiating supplemental oxygen. The resident was an elderly female with dementia, dysphagia, and chronic kidney disease who had recently been treated with antibiotics and prednisone for walking pneumonia. On 1/7/26 at 2:10 PM, an RN documented that the resident’s SpO2 was 82% during a breathing treatment, that the resident attempted to eat breakfast and did not want to continue the treatment, and that oxygen was applied and tolerated. However, there was no documentation of repeat vital signs or oxygen saturation after the administration of supplemental oxygen, and the RN acknowledged in interview that she believed she had entered follow-up information but it was not present in the EMR. She also confirmed she began oxygen without a physician’s order, relying on standing orders, and recalled use of an oxygen mask that was not documented. On 1/8/26 at 11:35 AM, an LPN documented that the resident’s oxygen saturation dropped with oxygen titration after finishing the course of antibiotics and prednisone for walking pneumonia, and that the resident had decreased appetite, weakness, and was sleeping during the shift, and stated she wanted to go to the hospital. The LPN contacted the medical director, who ordered transfer to the ER, but could not recall who ordered the titration of supplemental oxygen and suggested it may have been something they “just tried” or possibly directed by the ADON. Review of the EMR showed an order for oxygen at 8 L/min via nasal cannula starting 1/7/26, but no repeat vital signs were documented after the change in condition. The DON stated she expected to see follow-up documentation, including repeat vitals and physician notification if the condition did not improve, and clarified that standing orders allowed only up to 2 L of oxygen without a physician’s order and that titration should occur only under physician direction. Facility policies required initiation of 2 L O2 and physician notification if SpO2 was below 89%, and prompt physician notification for significant changes in condition requiring alteration of medical treatment.
Failure to Test Symptomatic Resident for COVID-19 per Facility Protocol and CDC Guidance
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and CDC guidance for testing residents with new respiratory symptoms. A female resident with dementia, dysphagia, and chronic kidney disease was admitted on an unspecified date and later developed respiratory symptoms. On 12/29/25, a physician communication note documented that the resident presented with a congested cough, rhonchi throughout both lungs, and some weakness. The resident had existing physician orders dated 12/20/25 and 12/26/25 for SARS-CoV-2 (COVID-19) testing as needed per facility protocol, but there was no evidence that a COVID-19 test was ordered or performed after the onset of these symptoms. A complaint submitted to the State Agency on 1/28/26 stated that the resident was transferred to an emergency room on 1/8/26 with severe respiratory issues and was confirmed COVID-positive, and that the nursing home did not test her when she first showed symptoms, treating her only for pneumonia. During interviews, the ADON/Infection Preventionist explained that symptomatic residents should be tested for COVID-19 per facility protocol and identified symptoms warranting testing as sore throat, congestion, cough, fever, and fatigue. The ADON/IP confirmed that the resident was not tested for COVID-19 after respiratory symptoms began on 12/29/25 and stated that because the resident was being treated for pneumonia, it had “slipped my mind” to test for COVID-19, acknowledging that the resident should have been tested at symptom onset. This failure was inconsistent with the facility’s written Infection Prevention and Control Program, which required viral testing for anyone with even mild COVID-19 symptoms, and with CDC guidance directing testing of residents and HCP with new respiratory illness signs or symptoms.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents with cognitive impairments and special dietary needs. One resident with Alzheimer's disease and a mechanical soft diet was observed repeatedly accessing and consuming discarded food from an unattended meal cart in the dining room without staff intervention. The resident was also given a sandwich that did not meet her dietary restrictions, resulting in her struggling to eat and dropping food on the floor. Multiple staff interviews confirmed that there were not enough staff present to monitor residents adequately, and that dietary orders were not consistently followed, increasing the risk of choking for the resident. Another resident with dementia and severe cognitive impairment, who required substantial assistance with eating, was left unsupervised in the dining room. This resident sustained second- to third-degree burns after spilling hot coffee on herself. The coffee was provided without a lid, despite care plan instructions, and staff acknowledged that the coffee was too hot and that a lid was needed. The staff member responsible was distracted due to short staffing and did not return with the lid before the resident was given the coffee. The burn resulted in significant injury, including blistering and pain, as documented in the resident's medical record and skin evaluation photos. Staff interviews consistently reported ongoing staffing shortages, which contributed to lapses in supervision, failure to follow dietary orders, and inability to provide adequate care. Staff expressed concerns about being unable to monitor all residents, leading to missed care and increased risk of harm. Grievance forms and care plan reviews further documented these deficiencies, with staff acknowledging that the current staffing levels made it difficult to ensure resident safety and compliance with care requirements.
Failure to Provide Sufficient Nursing Staff Resulting in Resident Harm and Missed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. Several residents were found with poor hygiene, such as long, dirty fingernails, soiled clothing, and unclean bedding. Staff reported being frequently mandated to work extended shifts, leading to burnout and an inability to complete all required care tasks. Certified Nurse Aides (CNAs) and an LPN described having to cut corners on resident care, including missing nail care, hygiene, and timely response to call lights, due to chronic understaffing and high rates of staff call-ins and turnover. One resident with a seizure disorder and severe cognitive impairment was observed in a disheveled state, with soiled clothing and untrimmed, dirty fingernails. Another resident, who was cognitively intact but fully dependent for toileting and bathing, reported waiting over an hour for call light responses and experiencing soiled bedding and skin. This resident also described refusing care at times because staff were rushed and unable to provide care in a respectful manner. Staff confirmed that these issues were due to insufficient staffing levels, which made it difficult to provide adequate supervision and assistance to all residents. A resident with Alzheimer's disease and swallowing difficulties was observed eating food from discarded trays and being given food inconsistent with her prescribed mechanical soft diet, without adequate staff supervision in the dining area. Another resident suffered a third-degree burn from hot coffee when a CNA, distracted by other resident needs and short staffing, failed to ensure the coffee was safe before serving it. Staff interviews consistently attributed these incidents to inadequate staffing, which resulted in missed care, lack of supervision, and direct harm to residents.
Failure to Maintain Resident Dignity and Personal Hygiene Due to Inadequate Staffing
Penalty
Summary
The facility failed to maintain resident dignity and provide adequate personal hygiene for three residents, as evidenced by multiple observations and interviews. Residents were noted to be disheveled, with soiled clothing, untrimmed and dirty fingernails, and, in one case, matted hair. One resident with severe cognitive impairment was observed with dried food on his shirt, food crumbs in his lap, and significant dirt under his fingernails. Another resident, who was cognitively intact but physically dependent, was found with very dry, peeling skin, untrimmed and dirty fingernails, and soiled bedding with food crumbs and stains. This resident reported waiting extended periods for staff to respond to call lights and sometimes refused care due to staff rushing and perceived rudeness, attributing these issues to short staffing. Staff interviews confirmed that chronic understaffing and frequent mandatory overtime led to rushed care and the need to cut corners, particularly in areas such as nail care, hygiene, and timely response to call lights. Certified Nurse Aides reported being mandated to work double shifts, frequent call-ins, and burnout, which resulted in residents not receiving the care they deserved. Staff also indicated that other personnel with CNA licenses rarely assisted with time-consuming tasks like bathing, nail care, and feeding, further exacerbating the problem. Facility policies and job descriptions reviewed during the survey emphasized the importance of maintaining resident dignity and providing assistance with activities of daily living according to care plans. Despite these policies, the observed deficiencies in personal hygiene and resident appearance, as well as resident and staff reports of inadequate care, demonstrated a failure to uphold these standards. The lack of sufficient staffing and support directly contributed to the inability to provide dignified and respectful care to residents.
Food Safety Violations in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 53 residents. During an observation, a snack cart was left unattended in the hallway with an uncovered container of ice cubes used for filling resident drinking water cups. The Activity Aide confirmed he was not instructed to cover the ice cubes, which is a violation of the FDA Food Code 2017 that requires food to be protected from contamination. In another instance, during the noon meal service, hamburger patties were found at an unsafe temperature of 120 F in the steam table. The staff member responsible admitted to not reheating the patties to the required 165 F for 15 seconds before placing them in the steam table, which is only meant for maintaining food temperature. The staff member was unaware of the proper reheating requirements, indicating a lack of knowledge about food safety standards. Additionally, the facility's procedure for testing sanitizing solutions was inadequate. Staff members were observed using test strips incorrectly, not measuring the water temperature, and failing to achieve the proper concentration of sanitizer. The water temperature was too high, and the concentration of sanitizer was below the required level. Staff admitted they were not aware of the correct procedures for testing sanitizing solutions, which is a violation of the FDA Food Code 2017 that requires accurate measurement of sanitizing solutions.
Facility Environment Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functional environment for its residents, staff, and the public, potentially affecting all 53 residents. During an inspection, an exit door identified as Exit #4 was found to have a gap between the threshold and the bottom of the door, allowing cold air and potentially insects and vermin to enter the building. The Maintenance Director confirmed the door was in disrepair and needed replacement. Additionally, a community shower room was observed with a vertical wall missing eight ceramic tiles, exposing sharp edges that could cause injury. The Maintenance Director acknowledged the missing tiles and stated that replacements were unavailable, leading to the removal of the remaining tiles, which left the underlying drywall board exposed. Further inspection revealed issues in the kitchen's dishwashing area, where an atmospheric vacuum breaker connected to the garbage disposal was not intact, with the top bell housing missing. This defect could lead to a failure in the device during a negative pressure event in the potable water supply system, potentially causing contaminated liquids to backflow into the drinking water supply for the entire building. These deficiencies highlight significant lapses in maintaining a safe and functional environment within the facility.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives related to code status were accurately and timely completed for four residents. Resident #6 had a Code Status form that was improperly documented, with the facility staff witnessing the form before the resident's legal guardian signed it. Resident #26's previous Code Status form was missing, and a new form was completed on the day of the survey, indicating a lack of documentation from admission until that day. Resident #46 did not have an advance directive completed upon admission, and the Social Services Designee admitted to not filling out a new directive as required. Resident #50's documentation was incomplete, with only one witness signature instead of the required two. The facility's policy mandates that residents' code status be reviewed at least quarterly, but this was not adhered to in these cases. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to properly document and manage advance directives for these residents, which included those with conditions such as dementia, heart failure, and diabetes.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and homelike environment for its residents, as evidenced by multiple observations of strong odors and inadequate room aesthetics. On several occasions, surveyors noted a pervasive odor of urine and feces in various areas of the facility, including near the Hall B nurses' station, the resident room hall, and the hall outside the kitchen and dining room. Certified Nurse Aide (CNA) Q and other staff members were unable to identify the source of the odors, although it was suggested that they might be emanating from the air vents or the soiled utility room. The odors were persistent over several days, indicating a systemic issue with odor management in the facility. In addition to the odor issues, the facility also failed to maintain the aesthetic quality of resident rooms. Observations revealed that window draperies in some rooms were improperly fastened with paper clips and could not be fully closed, which was acknowledged by residents as unsatisfactory. Maintenance Director (Staff) D confirmed that the condition of the draperies was not conducive to a homelike environment and should have been addressed by the staff. Furthermore, cork bulletin boards in residents' rooms were found to be insecurely attached or leaning against walls, posing potential safety hazards. Staff D admitted that these issues were not recorded in the maintenance binder, which is used to track and address maintenance concerns. The facility's failure to address these environmental deficiencies was further highlighted by the lack of communication and documentation regarding maintenance needs. Staff D and the Nursing Home Administrator (NHA) acknowledged that the state of the bulletin boards and draperies did not meet the facility's aesthetic expectations. The NHA noted that these issues should have been documented in the maintenance binder to ensure timely repairs. The facility's policy on resident rights emphasizes the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inadequate Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that staff in the food and nutrition services had the appropriate competencies and skills, which could potentially lead to unsafe practices in the kitchen and dietary services affecting all 53 residents. During an observation, the three-compartment sink was used for washing, rinsing, and sanitizing food contact surfaces. However, the Kitchen Manager (KM) A was unable to demonstrate the proper testing procedure to ensure the correct concentration of sanitizing chemicals. Additionally, another staff member, [NAME] C, was also unable to demonstrate the procedure and confirmed that no training had been provided by KM A. Further investigation revealed that KM A had not completed the Certified Dietary Manager (CDM) program, having only finished one out of ten required modules over two years. Despite being in the position of manager of dietary services for almost three years, KM A only held a Certified Food Manager (CFM) credential. The FDA Food Code requires the person in charge of a food service operation to demonstrate knowledge of foodborne disease prevention and other critical principles, which was not adequately demonstrated by KM A.
Deficient Food Service Practices
Penalty
Summary
The facility failed to provide food in a manner that was palatable and at a safe and appetizing temperature for 10 residents. During a group interview, several residents expressed dissatisfaction with the cold temperature of their meals, including pizza and noodles, which were described as undercooked and bland. One resident mentioned receiving a hard-boiled egg with the shell on, which they could not peel due to arthritis, and no assistance was provided. Another resident complained about the quality of their meal, which included plain pasta, mushy zucchini, and hard cauliflower. A resident also reported significant weight loss due to the poor quality of food. Observations revealed that meal trays were delivered from un-insulated metal carts, resulting in food temperatures ranging from 102°F to 109°F, which is below the recommended serving temperature. The kitchen manager admitted that the staff was supposed to peel eggs for residents who couldn't do it themselves but had not considered the difficulty of removing all the shells. The menu did not specify that the eggs would be served unpeeled. These findings indicate a failure to ensure that meals were served at appropriate temperatures and in a form that residents could consume comfortably.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications before initiating them for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, was prescribed quetiapine fumarate and sertraline without prior consent from the guardian. The guardian, who had legal authority over the resident's treatment decisions, reported a lack of communication from the facility regarding these treatment decisions. Interviews with the Director of Nursing and the Social Services Designee revealed that obtaining consents for mood-altering medications had been a recognized issue within the facility. The facility's policy required that residents and/or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments. However, verbal consent for the medications was only obtained from the guardian approximately 1 year and 8 months after the medications were initiated, indicating a significant lapse in following the facility's policy and ensuring informed consent.
Failure to Conduct Quarterly Care Conferences and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that care conferences were scheduled on a quarterly basis and that the responsible party was notified, resulting in a deficiency in resident rights. This issue was identified for one resident, who had severe cognitive impairment due to Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. The resident's guardian reported not being given the opportunity to participate in regular care conferences, having only been involved in two since the resident's admission. The facility's records showed that care conferences for the resident were held on three occasions, with significant gaps of 9 and 5 months between them, despite the requirement for quarterly meetings. Interviews with facility staff, including the Social Service Designee and the Nursing Home Administrator, confirmed the lack of a regular care conference process under previous administration. The facility's policy mandates that comprehensive care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Conduct Quarterly Assessments for Self-Administering Resident
Penalty
Summary
The facility failed to perform a resident assessment for a resident who was self-administering medication, resulting in a deficiency. The resident, who had been admitted with diagnoses including peripheral vascular disease, scored a perfect 15 on the Brief Interview for Mental Status, indicating intact cognition. Despite this, the facility did not conduct the required quarterly assessments to ensure the resident's continued ability to safely self-administer medication. The last documented assessment was on 7/23/24, and no subsequent assessments were found in the resident's electronic medical record. Interviews with the Assistant Director of Nursing and a Registered Nurse revealed that the facility's policy required quarterly assessments for residents self-administering medication. However, it was acknowledged that the quarterly assessment for the resident in question was missed. The facility's policy also stipulated that a licensed nurse should complete a Medical Self-Administration screening tool in the electronic medical record, and reassessments should be considered quarterly by the interdisciplinary team. The failure to adhere to these procedures led to the resident self-administering medication without the appropriate assessments being conducted.
Inappropriate Incontinence Briefs Provided to Residents
Penalty
Summary
The facility failed to provide appropriately sized and styled incontinence briefs to meet the needs and preferences of two residents, resulting in discomfort and dissatisfaction. Resident #23 expressed dissatisfaction with wearing incontinence briefs that did not fit properly, as the size had been changed from XXL to Large, which did not cover the waist adequately. The resident had been complaining to a CNA for at least a week. Observation confirmed that only size Large briefs were available in the resident's closet, which did not fit properly. Resident #26 was observed wearing an incontinence brief that appeared too small, causing discomfort. The resident expressed a preference for pull-up style briefs, which were not provided, as they were told the current style held more urine. The Assistant Director of Nursing acknowledged the need for accurate waist measurements to determine the appropriate size and style of briefs, and confirmed that the residents' preferences should be considered. The Nursing Home Administrator was informed of the deficiency concern.
Unauthorized Withdrawal of Resident Funds
Penalty
Summary
The facility failed to obtain authorization prior to withdrawing personal funds for a resident with severe cognitive impairment. The resident, diagnosed with Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, had a BIMS score of 3, indicating severe cognitive impairment. The resident's guardian reported that the facility withdrew $500 from the resident's trust fund without authorization and applied it to the facility bill. The guardian stated that the funds were intended for personal use, such as haircuts, shopping, and snacks. The Business Office Manager (BOM) confirmed the withdrawal and stated that verbal consent was received from the guardian, but no receipt or written documentation was provided. The facility's policy requires a receipt for any transaction involving resident funds, and the Nursing Home Administrator confirmed the need for written authorization before withdrawing money from resident accounts. The BOM acknowledged the oversight and recognized the need for proper documentation in future transactions.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, as required by their policy. The resident, who has Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, did not receive the necessary financial statements despite requests from their guardian. The facility had recently transitioned to using their own EMR system to manage resident fund accounts, and the Business Office Manager (BOM) indicated that the previous management service did not provide access to verify if statements were sent. The Nursing Home Administrator (NHA) acknowledged the issue and intended to contact the management service to confirm the status of the statements, but no statements were provided by the time of the survey exit.
Failure to Provide Timely Medicare Termination Notices
Penalty
Summary
The facility failed to provide a 48-hour notice of termination of Medicare benefits for three residents, which resulted in the residents' inability to appeal their non-coverage decision in a timely manner. Resident #8, who had severe cognitive impairment due to Alzheimer's disease and other mental health conditions, did not receive any beneficiary notification since admission, as confirmed by both the complainant/guardian and the responsible registered nurse. The Director of Rehabilitation confirmed that Resident #8 received skilled therapy services under Medicare Part B, but there was no record of a notification being issued. For Resident #204, the Notice of Medicare Non-Coverage (NOMNC) form was signed one day before the effective date of coverage termination, and similarly, for Resident #205, the NOMNC form was signed one day before the end of coverage. The facility's policy requires that such notices be provided at least two days before the end of Medicare-covered services, but this was not adhered to in these cases. The failure to provide timely notifications is a violation of the facility's policy and federal regulations, impacting the residents' rights to make informed decisions about their care and financial responsibilities.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the reasons for transfers to an acute care hospital. The resident, who had intact cognition as indicated by a BIMS score of 15, was hospitalized three times since their initial admission. Despite these hospitalizations, the resident did not recall receiving or signing any transfer notification documents prior to being transferred. The facility's records confirmed the resident's transfers occurred on three separate occasions due to medical emergencies, including a dehisced surgical incision, uncontrollable shaking with cyanosis, and a need for evaluation and treatment in the emergency room. However, a review of the electronic medical record revealed no written transfer notices were provided before any of these hospitalizations. Additionally, an interview with the Social Services Designee revealed a lack of familiarity with the transfer notification process, further indicating a deficiency in the facility's adherence to its own policy on transfer and discharge.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update or revise the care plan for a resident after multiple falls, which was identified as a deficiency. The resident, who has active diagnoses including dementia, diabetes, hypertension, and anemia, was admitted to the facility and was noted to rarely or never be understood or make decisions. The resident experienced one fall in August, two falls in October, and two falls in November. Despite these incidents, the care plan was not revised after any of the falls. The facility's policy on incidents and accidents emphasizes the importance of implementing appropriate and immediate interventions and corrective actions to prevent recurrences, which was not adhered to in this case.
Inadequate Pressure Ulcer Prevention and Infection Control
Penalty
Summary
The facility failed to maintain proper infection control and implement effective interventions for the prevention and treatment of pressure injuries for three residents. For Resident #11, during a wound care observation, an LPN used her personal cell phone without changing gloves, contaminating the wound supplies and the wound itself. The LPN also placed a foam dressing on the resident's bed linens instead of a sterile barrier, further compromising infection control standards. Resident #26 reported a sore area on the tailbone, and during a wound care observation, it was noted that the resident's heels were in contact with the bed mattress, with one heel showing signs of redness and sponginess. The facility's standing orders and policies were not followed, as the resident did not have an air mattress or proper heel elevation to prevent pressure injuries, despite being at risk. Resident #54 developed a Stage 2 pressure ulcer on the coccyx after admission, despite not having any pressure ulcers upon entry to the facility. The DON acknowledged that an air mattress should have been provided earlier, and the resident was not educated on the risks of pressure ulcers. The facility's failure to implement timely and appropriate pressure redistribution measures contributed to the development of the pressure ulcer.
Failure to Investigate Resident's Burn Injury
Penalty
Summary
The facility failed to investigate an accident involving a resident who sustained a burn injury while smoking. The resident, who has intact cognition and a history of diabetes mellitus, anxiety disorder, depression, and hypertension, was observed with a scab on his right middle finger. The resident reported that he burned himself while smoking cigarettes down to the filter, and staff did not notice his actions. The resident was informed that his smoking privileges would be revoked if the incident occurred again. The facility's policy requires staff to report, investigate, and review any accidents or incidents involving residents. However, there was no incident or accident report for the resident's burn injury. The Assistant Director of Nursing was aware of the blister but not the cause. The facility's failure to document and investigate the incident is a deficiency in adhering to their policy, which mandates documentation of the date, time, nature of the incident, location, initial findings, immediate interventions, notification, and follow-up interventions for unobserved injuries.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents. Resident #8, diagnosed with Alzheimer's disease, vascular dementia, and other mental health conditions, was prescribed quetiapine fumarate and sertraline without documented consent or specific non-pharmacological interventions in the care plan. The Director of Nursing acknowledged missing AIM assessments and consent issues, while the Social Services Designee confirmed the lack of timely consent. Resident #33, with multiple diagnoses including anxiety disorder and dementia, was prescribed several psychoactive medications without justification for continued use or proper consent documentation. The facility failed to provide signed consents for the use of haloperidol and other medications until recently, despite the medications being administered for an extended period. The Social Services Designee admitted to the absence of previous consents before the newly signed documents. Resident #38, with Alzheimer's disease and schizophrenia, was prescribed olanzapine without a signed consent from the legal guardian. Additionally, the resident had not received an AIM assessment since March 2022. The facility's policy requires education on psychotropic drug use and non-pharmacological interventions, as well as regular AIM assessments, which were not adhered to in these cases.
Medication Administration Errors Observed in Insulin Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during the observation of medication administration for a resident. The errors were observed during the administration of insulin by a Registered Nurse (RN) to a resident. The RN did not disinfect the hub of the humalog insulin pen before attaching the needle and failed to prime the pen properly, which is necessary to ensure accurate dosing. The RN acknowledged the oversight and attempted to correct the process but still did not prime the pen before administering the insulin. Additionally, the RN made errors while preparing the lantus insulin pen by priming it incorrectly and not following the proper procedure to ensure accurate dosing. The Assistant Director of Nursing (ADON) was consulted and confirmed the errors in the insulin administration process. The instructions for both the humalog and lantus insulin pens clearly state the need for priming to avoid air bubbles and ensure accurate dosing, which was not adhered to during the administration process.
Failure to Perform TB Screenings for Staff and Residents
Penalty
Summary
The facility failed to perform pre-employment and pre-admission screenings for tuberculosis (TB) based on current professional guidelines. During a review of staff records from January 2024 through April 2024, it was found that no TB screening information was available for several newly hired employees, including dietary aides, certified nurse aides (CNAs), and housekeeping aides. The Office Manager confirmed that the head of each department was responsible for ensuring TB screenings, but no documentation was provided for the sampled employees. The Nursing Home Administrator (NHA), who was also the interim Infection Preventionist, acknowledged the issue but had not made any changes to the process as of the survey date. The NHA confirmed that no TB screening information was found for the newly hired staff members listed in the report. Additionally, a review of electronic medical records (EMRs) for residents admitted within the past 30 days revealed that several residents did not have TB screening information prior to or since their admission. The NHA confirmed that the staff responsible for TB screening of newly admitted residents did not understand the process. The facility's policy on TB screening, which aligns with CDC guidelines, was not followed, resulting in the potential for exposure and transmission of TB to susceptible residents. The NHA confirmed that residents admitted within the specified period were not screened for TB, highlighting a significant lapse in infection control practices.
Call Light Accessibility for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a visually impaired resident (R16). R16, who was admitted with diagnoses including legal blindness, dementia, anxiety, and depression, was observed on multiple occasions unable to locate her call light. On one occasion, R16 was found sitting in her wheelchair, facing the wall with an over bed table in front of her, and the call light wrapped around the left upper grab bar of the bed, out of her reach. R16 reported she often could not find the call light and was observed patting her hands around her lap and the table in an attempt to locate it. The call light was confirmed to be out of reach by both the resident and the surveyor's observations. On another occasion, R16 was heard calling for help repeatedly and was found in a similar position with the call light lying on the floor, two feet away from her and on the opposite side of the over bed table. R16 expressed frustration at not being able to find the call light and needing assistance to go back to bed. An LPN confirmed the call light was out of reach and activated it for assistance. The LPN also found a small metal clip on the call light cord that was not being used to secure the light near the resident. The Director of Nursing confirmed that call lights should always be accessible to residents, especially those with severe visual impairments like R16.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignified treatment during the provision of care for two residents. One resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed lying naked from the waist down while the CNA and the Nursing Home Administrator were out of sight. This occurred during incontinence care when the CNA left to wash her hands and the NHA went to retrieve a clean brief, leaving the resident exposed and unattended on the bed. Another resident, also with severe cognitive impairment, was observed sitting on the toilet with her pants and brief pulled down below her knees, fully visible from the hallway. The privacy curtain was not drawn, and the door to the shower room was fully open. A staff member walking down the hallway noticed the exposed resident and subsequently drew the privacy curtain. The Director of Nursing confirmed that all residents should be cared for in a manner that preserves their dignity, including ensuring privacy during toileting and covering exposed body parts during care.
Failure to Maintain Safe and Clean Resident Rooms
Penalty
Summary
The facility failed to ensure resident rooms were maintained in a safe, clean, and homelike manner for two residents. Resident R13, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and stroke, was observed with her mattress directly on the floor without sheets or a mattress protector. The floor around her mattress was visibly soiled with dirt and shoe prints, and a sticking sound was noted when walking on it. The mattress and a fall mat were positioned askew, protruding into the portion of the room belonging to Resident R19, who was cognitively intact and had diagnoses including COPD and bipolar disorder. R19 reported difficulty maneuvering her wheelchair around the mattress and had previously reported the issue to staff without resolution. Additionally, the wall near R19's dresser had deep gouges, and an uncovered utility box with a protruding screw was found, posing potential safety hazards. Certified Nurse Aide Supervisor (CNA) F confirmed that R13's mattress was on the floor as per her care plan, and that R13 often crawled around on the floor. Maintenance and Housekeeping Director (Staff L) was unaware of the uncovered outlet box and the disrepair in the room, confirming the visibly soiled floor. Housekeeping Aide (Staff T) reported not receiving notification about the soiled floor, and Housekeeping Aide (Staff S) stated the room was last cleaned the previous day but did not recall the time. The facility's maintenance log showed no entries for the uncovered outlet box or the wall damage. The Nursing Home Administrator (NHA) and Regional Administrative Consultant (Staff A) acknowledged the observations and instructed maintenance staff to inspect all utility outlets facility-wide and housekeeping staff to clean R13 and R19's room twice daily. However, these actions were taken after the surveyor's observations and are not part of the deficiency itself.
Failure to Ensure Safe Transfers for Residents
Penalty
Summary
The facility failed to ensure safe transfers for two residents, resulting in the potential for falls and injury. Resident 13, who has diagnoses including dementia, Parkinson's disease, muscle weakness, and abnormalities of gait/mobility, was observed being assisted to the toilet without the use of a gait belt, contrary to the care plan which required extensive assistance and the use of a gait belt. The care plan also indicated that Resident 13 was at high risk for falls. Similarly, Resident 18, who has severe dementia and a history of falls, was observed being transferred from a wheelchair to a bed without the use of a gait belt or any other assistive device, despite the care plan specifying the use of a gait belt and a front-wheeled walker for transfers. The CNA assisting Resident 18 was unaware of the resident's transfer needs and had not checked the care plan prior to the transfer. The Director of Nursing confirmed that the use of gait belts during transfers is a standard practice and that staff should check the care plan when unsure of a resident's transfer status. The facility's policy on Safe Resident Handling/Transfer, last reviewed in June 2023, mandates that residents be handled and transferred safely according to their individual care plans to prevent injury. The failure to adhere to these policies and care plans led to the observed deficiencies in resident care and safety during transfers.
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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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