Hampton Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bay City, Michigan.
- Location
- 800 Mulholland Road, Bay City, Michigan 48708
- CMS Provider Number
- 235411
- Inspections on file
- 19
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Hampton Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain adequate nursing staff coverage, particularly on weekends and certain shifts, resulting in unmet resident care needs such as long wait times for assistance, missed showers, and resident frustration. Staffing records and interviews confirmed frequent call-ins, difficulty filling open positions, and reliance on bonuses to encourage staff to work extra shifts, but these measures were insufficient to ensure consistent coverage.
Residents reported that their care needs were frequently unmet due to insufficient staffing and the conduct of a specific aide, resulting in long wait times for assistance, missed showers, and lack of help with meals. Multiple residents described being treated disrespectfully, with one aide characterized as rushed and rude, leading to feelings of diminished self-worth and unmet needs.
Surveyors found that the facility failed to maintain clean and safe shower rooms, with black residue, chipped tiles, and a non-functioning shower, resulting in an environment that did not meet regulatory standards for cleanliness and comfort.
Surveyors found that the facility did not follow care plans for ADL and wound care for three residents, resulting in missed showers, inadequate hygiene, and a missed dressing change for a post-surgical wound. Documentation was inconsistent, and required interventions for refusals or missed care were not in place.
Multiple dependent residents did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Only one shower was available for all residents due to facility infrastructure issues, and care plans lacked interventions for refusals or alternative hygiene measures. Residents expressed dissatisfaction and emotional distress, and documentation did not reflect appropriate hygiene care or strategies for managing refusals.
A resident with a post-surgical back incision did not receive a daily dressing change as ordered, with observation showing the same dressing in place for two days. Nursing staff documented the dressing change as completed, but the physical evidence and resident interview indicated otherwise. The DON confirmed that dressing changes should be completed as ordered and by the next shift if missed.
A resident with severe cognitive and physical impairments, identified as very high risk for pressure injuries, was repeatedly found without required positioning devices and developed multiple open areas of skin breakdown under the left breast. Staff failed to follow care-planned interventions for repositioning and did not document or report the new skin breakdown, despite clear risk factors and facility guidelines.
A medication cart was found unlocked and unattended in a hallway, allowing access to medications by residents, visitors, and staff. The assigned RN was in a resident's room at the time, and the cart was accessible to the state surveyor, who was able to open its drawers. The RN had previously received inservice training on the requirement to keep medication carts locked when not in use, and facility policy prohibits leaving carts unlocked and unattended.
A resident who refused the RSV vaccine did not have a signed refusal form or documentation of vaccine education in the medical record. The electronic record included a blank consent form, and no progress notes indicated that education or refusal was addressed, even after the resident was readmitted with RSV.
A deficiency was cited due to the facility not being fully protected by an approved automatic sprinkler system as required by the 2012 standards for existing nursing homes and hospitals.
Surveyors found that the facility basement, which houses the laundry, employee break room, maintenance office, boiler room, storage, electrical room, and employee bathroom/locker room, had only one exit instead of the two required by NFPA 101. This deficiency was confirmed by interviews with facility leadership and could affect about 10 occupants in an emergency.
Surveyors found that a sprinkler head in the main lobby near the front egress door was installed too close to a light fixture, in violation of NFPA 13 requirements. This placement could alter the water flow pattern and does not provide proper sprinkler protection, as confirmed by interviews with facility leadership.
The facility failed to ensure that call lights and privacy curtains were accessible to residents, leading to unmet care and privacy needs. Observations showed that privacy curtains were out of reach in several rooms, and a resident's call light was placed four feet away, making it inaccessible. A CNA admitted to not using the privacy curtain during a care task, further compromising resident privacy.
The facility failed to provide adequate ADL care for four residents, leading to issues such as long fingernails, missed showers, and unkempt appearances. One resident missed scheduled showers, another had long nails and dirty palms, a third reported missed showers due to staff availability, and a fourth was left in a nightgown for days with their call light out of reach. These deficiencies indicate a failure to adhere to the facility's policy on maintaining residents' ability to perform ADLs.
A resident developed a facility-acquired pressure injury on the left heel due to the facility's failure to prevent it and ensure timely nutritional care plans. Despite being alert and oriented, the resident experienced significant weight loss and inconsistencies in receiving prescribed nutritional interventions. Interviews revealed a lack of awareness and follow-up by the dietary manager and registered dietician regarding the resident's nutritional needs and preferences.
A resident with contracted hands was observed multiple times without the required bilateral palm protectors, as specified in their care plan. The Therapy Director confirmed the need for these protectors during the day, but they were found unused in the resident's nightstand. The resident's care plan included instructions for applying the protectors, and staff had been educated on their use.
A nurse improperly stored narcotics for a resident by placing them in a medication cart drawer instead of following proper storage procedures. The nurse prepared the medications, including Norco and Pregabalin, and when the resident requested to take them later, the nurse stored them in the drawer. The Director of Nursing acknowledged the error, noting it was against the facility's Controlled Substances Policy.
A resident experienced significant weight loss due to the facility's failure to honor her dietary preferences and provide palatable meals. Despite being on a Controlled Carbohydrate Diet and No Added Salt diet, the meals served were high in carbohydrates and sugar, contrary to her needs for managing Type 2 Diabetes. The resident's documented preferences, such as the inclusion of strawberries and cottage cheese, were not followed, leading to reduced food intake and frustration.
A facility failed to ensure proper communication and documentation of hospice services for a resident, leading to a lack of progress notes and assessments in the medical record. The resident was found uncomfortable, and the unit nurse had not notified the hospice agency about symptoms. The hospice services binder lacked documentation, and there was a delay in scanning progress notes into the EMR. Additionally, Morphine Sulfate was administered at incorrect intervals, with no changes in the prescribed order noted.
The facility failed to implement Enhanced Barrier Precautions, as staff were observed not wearing required PPE in designated rooms. A nurse and a CNA were seen without gowns during high-contact activities, and a housekeeper cleaned an EBP room without a gown. These actions violated the facility's policy and physician orders, risking cross-contamination.
Deficiency Due to Insufficient Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and review of staffing records. Residents reported long wait times for assistance, particularly on weekends and during certain shifts, with one resident stating she waited 30-45 minutes for help and experienced incontinence as a result. Several residents expressed frustration about insufficient staff coverage, especially on weekends and second shift, and noted that call lights were not answered promptly. Review of the facility's PBJ (Payroll-Based Journal) staffing data for the first quarter of 2025 revealed low weekend staffing. The facility's policy states that sufficient numbers of licensed nurses and CNAs are to be available 24/7, but interviews with staff and review of schedules indicated frequent call-ins and difficulty filling open positions, particularly on weekends. The facility attempted to address call-ins by offering bonuses and asking staff to stay over, but gaps in coverage persisted. The Human Resources staff confirmed that agency staff were not used and that new hires often did not remain after orientation, further contributing to staffing shortages. Staffing levels discussed included a requirement for 4 CNAs and 2 nurses on day and afternoon shifts, and 1-2 CNAs and 2 nurses on night shift, depending on census. Despite these requirements, both residents and staff reported that actual staffing often fell short, especially on weekends. The facility's inability to consistently provide sufficient nursing staff resulted in unmet resident care needs, including missed showers and delayed responses to call lights, leading to resident dissatisfaction and compromised care.
Failure to Ensure Dignity and Timely Care Due to Staff Conduct and Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and had their needs met in a timely manner, as required by resident rights regulations. Multiple residents reported that their care needs were only met about half the time, with specific complaints about insufficient staffing, long wait times for assistance, and lack of responsiveness to call lights. Residents described being left on the toilet for extended periods, missing scheduled showers due to staff shortages, and not receiving help with meal setup. One resident, who used a writing board for communication, reported that an aide told them to "do it on your own" when they requested help. During a resident council meeting, all residents present unanimously stated that they did not receive care when needed, citing frequent understaffing and inconsistent aide performance. Specific complaints were made about a particular aide, who was described as rushed, rude, and dismissive. Residents recounted instances where the aide snapped at them, made insensitive remarks, and failed to provide timely incontinence care. Two residents reported that their call light was left unanswered for extended periods, resulting in one resident being unable to access a bedpan in time. The aide's behavior was characterized as lacking in customer service, with residents feeling talked down to and experiencing diminished self-worth. These findings were based on direct resident interviews, observations, and review of facility records.
Deficient Shower Room Maintenance and Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in its shower rooms, as required by federal regulations. The only operational shower room in the building, located on the 100-Hall, had black residue on the wall tiles and caulking, with the residue appearing to be under the caulking and grout. Additionally, there was an area behind the shower curtain with approximately 10 inches of chipped-off tiles, exposing chipped drywall and sharp tile edges, all with visible black residue. The 200-Hall shower room was not in use, as the tub had been removed, and the shower was non-functioning. Interviews with facility staff confirmed awareness of the issues, with the Administrator providing repair quotes for both shower rooms and Maintenance staff indicating that repairs for the 100-Hall shower were scheduled to be completed within 30 days. The 200-Hall shower had a repair quote from several months prior, but repairs had not yet been initiated, as the plan was to address the 100-Hall shower first. These conditions resulted in a failure to provide a sanitary, orderly, and comfortable environment for residents requiring hygiene services.
Failure to Follow Care Plans for ADL and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow comprehensive care plans for activities of daily living (ADL) and wound care for three residents. For one resident with Alzheimer's disease, anxiety, and depression, the care plan required staff assistance with bathing and showers twice weekly. However, documentation showed that over a 30-day period, the resident received only one shower and no bed baths, despite the care plan's requirements. There were also insufficient interventions documented for instances when the resident refused showers, and progress notes only sporadically recorded refusals. Another resident, newly admitted with a right toe amputation and a lack of self-care, was observed to have poor hygiene, including greasy hair, facial hair growth, and body odor. The care plan specified showers or bed baths twice weekly, but records indicated only one shower was provided in 14 days, with no documentation of refusals. Observations and interviews confirmed the resident's unkempt appearance and dissatisfaction with the frequency of personal care provided. A third resident, who had recently undergone back surgery, was observed with a surgical dressing that had not been changed as scheduled. The care plan required daily dressing changes, but the resident reported the dressing was not changed on the previous day due to a scheduled leave for a therapy evaluation. The nurse on duty stated that the dressing change was missed because the resident left before it could be completed, and the DON confirmed that dressing changes should be completed as ordered or by the next shift. Documentation inconsistencies were noted regarding whether the dressing change was performed as required.
Failure to Provide Scheduled ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically personal hygiene and showers, for five dependent residents. Observations and interviews revealed that residents often did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Documentation showed that some residents received only one shower in a 14- or 30-day period, with no evidence of bed baths being provided as alternatives. In several cases, there was no documentation of resident refusals for showers or baths, and care plans lacked interventions for refusals or alternative hygiene measures. The deficiency was further compounded by facility infrastructure issues, as only one shower was available for 48 residents due to the removal of a tub in one shower room, which was being used for storage. This limited access to bathing facilities made it difficult to meet the scheduled shower frequency for all residents. Residents expressed dissatisfaction and emotional distress due to missed showers, with some reporting feelings of neglect and sadness. Medical records indicated that the affected residents had significant self-care deficits due to conditions such as Alzheimer's disease, recent amputation, stroke, muscle weakness, Parkinson's disease, and obesity. Despite these needs, care plans did not address the lack of hygiene care or provide strategies for managing refusals. Observations confirmed ongoing issues with personal hygiene, including greasy hair, unshaven faces, and skin irritation, with no evidence of appropriate interventions being implemented.
Failure to Complete Daily Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when a resident with a post-surgical lower back incision did not receive a dressing change as ordered. Observation revealed that the dressing on the resident's back was dated two days prior, despite orders for daily dressing changes. The resident confirmed that dressing changes were supposed to occur every day and noted that he left the facility for a physical therapy home evaluation the previous day, but not until after 11:00 AM. Interview with the RN on duty indicated that she did not perform the dressing change before the resident left, and she cited frequent new admissions and discharges as factors affecting her ability to complete treatments. Review of the Treatment Administration Record showed that the night shift nurse had documented the dressing change as completed, but the physical observation contradicted this, showing the dressing had not been changed since two days prior. The DON confirmed that dressing changes should be completed as ordered and, if missed by one shift, should be done by the next.
Failure to Implement Care-Plan Interventions Leads to New Skin Breakdown
Penalty
Summary
A resident with a history of stroke, aphasia, and hemiplegia, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was identified as being at very high risk for pressure-related skin injuries based on a Braden Scale score of 8. Despite care plan interventions that included regular repositioning and the use of assistive devices to minimize skin breakdown, the resident was repeatedly observed resting in bed without positioning devices under their left arm. Multiple observations noted a strong odor in the room and under the resident's left breast, where open areas of skin breakdown were found. The care plan also required daily observation of skin condition and reporting of abnormalities, but the new skin breakdown under the left breast was not documented in the skin and wound evaluation prior to surveyor discovery. Further review revealed that the resident's left arm was nearly closed over the left breast, with no positioning device in place to aid in pressure reduction, and staff noted the resident sweated excessively. The facility's own skin management guidelines identified excessive perspiration as a risk factor for moisture-associated skin damage, yet these risks were not adequately addressed. The failure to implement care-planned interventions and to document and report new skin breakdown resulted in the development of multiple open areas under the resident's left breast, indicating a lack of adherence to professional standards of practice for the prevention and management of pressure ulcers.
Medication Cart Left Unlocked and Unattended in Hallway
Penalty
Summary
A medication cart on the 200 Hall was observed left unlocked and unattended in the hallway, making medications accessible to residents, visitors, and staff. The state surveyor was able to open drawers on the cart while the assigned RN was in a resident's room checking blood sugar and conversing with the resident. The RN acknowledged that the cart was left unlocked unintentionally when questioned by the surveyor. Review of the RN's employee record showed that she had previously received a one-on-one inservice in March 2025 regarding the requirement to keep medication and treatment carts locked at all times when not in use. The facility's policy also states that unlocked medication carts are not to be left unattended. The Director of Nursing confirmed awareness of the incident and reiterated that medication carts should remain locked when the nurse is not present.
Failure to Document Immunization Education and Refusal
Penalty
Summary
The facility failed to provide proper documentation and education regarding immunization refusal for one resident among five reviewed for immunizations. Specifically, the resident had refused the RSV vaccine in December 2024, but there was no signed refusal form or progress note in the medical record to indicate that education about the vaccine's benefits and potential side effects had been provided, nor was there documentation of the refusal itself. The electronic medical record contained a blank vaccine consent form with no refusals or signatures, and the Infection Control Preventionist confirmed that the form was not filled out by staff. Further review of the resident's progress notes from late 2024 through mid-2025 revealed no entries regarding RSV vaccine education or refusal, even after the resident was readmitted from the hospital with a diagnosis of RSV following a respiratory illness. The lack of documentation persisted throughout the resident's stay, indicating that the facility did not follow its own policies and procedures for recording immunization education and refusal, as required by regulation.
Deficiency in Sprinkler System Installation
Penalty
Summary
A deficiency was identified regarding the installation of the sprinkler system. The report notes that nursing homes and hospitals, where required by construction type, must be protected throughout by an approved automatic sprinkler system. The facility did not meet this requirement, as the necessary sprinkler system installation was not in place as specified by the 2012 standards for existing buildings.
Plan Of Correction
Element 1: No residents were identified in this concern. The light fixture in the lobby was moved to accommodate the required distance from the sprinkler head. Completed by 7/24/2025
Failure to Provide Required Number of Basement Exits
Penalty
Summary
Surveyors observed that the facility failed to provide the required number of exits from the basement, as mandated by NFPA 101, sections 19.2.4.1 through 19.2.4.4. During an inspection, it was found that there was only one exit available from the basement, which is occupied by the laundry area (including a linen chute from the first floor), employee break room, maintenance office, boiler room, storage room, electrical room, and employee bathroom/locker room. This observation was confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of the survey. Approximately 10 occupants could be affected by this deficiency in the event of a fire emergency, as the basement does not meet the requirement for at least two remote and accessible exits from every story and compartment.
Plan Of Correction
Element 1 No residents were identified. Residents do not have access to the basement. Staff are aware of the emergency exit. Element 2 All other areas where residents have access to, have required exits. Element 3 The facility administrator has contracted with the LSC Specialist to conduct a Fire Safety Evaluate System (FSES) survey for a waiver request. The FSES will be completed on 7/18/2025 and forwarded to Life Safety for a waiver request. Element 4 Audit will be completed weekly regarding accessible exits on every story. Results will be reviewed with the Administrator and brought to monthly QAPI for review and recommendations. Administrator is responsible for compliance.
Sprinkler Head Installed Too Close to Light Fixture
Penalty
Summary
Surveyors observed that the facility failed to provide a sprinkler system installed in accordance with NFPA 13 requirements. Specifically, during an inspection, it was found that the sprinkler head located in the main lobby near the front egress door was positioned too close to a light fixture. This proximity was determined to be within a few inches, which does not comply with NFPA 13, 8.3.2.5, Table 8.3.2.5(c), as it could alter the water flow pattern and prevent proper sprinkler protection. These findings were confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of observation.
Plan Of Correction
Element 2: An audit of the facility determined that 3 additional light fixtures are located too close to the sprinkler heads. Element 3: Electrician is scheduled to move overhead lights to be completed by 7/24/2025. Element 4: EVS Director or designee will audit sprinkler heads weekly to ensure that they are not blocked and provide proper sprinkler protection. Results will be brought to weekly QA for review and recommendations. EVS Director is responsible for compliance.
Failure to Ensure Accessibility of Call Lights and Privacy Curtains
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not providing timely responses to call lights, ensuring call lights were within reach, and ensuring privacy curtains were accessible and used. Observations revealed that privacy curtains in rooms 100, 103, 107, 108, and 110 were tucked away out of reach, compromising the residents' privacy. Additionally, a resident was found with their call light placed approximately four feet away on a chair, making it inaccessible. This resident expressed a feeling of neglect, suggesting that the call light was intentionally placed out of reach. Further observations confirmed that privacy curtains remained out of reach in multiple rooms, even after the issue was brought to the attention of the Assistant Director of Nursing (ADON). A Certified Nursing Assistant (CNA) admitted to not pulling the curtain during a personal care task, citing the task's nature as the reason. These actions and inactions resulted in unmet care and privacy needs for the residents involved.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents, resulting in issues such as long jagged fingernails, missed showers, and an unkempt appearance. Resident #5, who is totally dependent on staff for personal hygiene, missed two scheduled showers within a 30-day period. Resident #21, who requires assistance due to anoxic brain damage and physical limitations, was observed with long, jagged nails and dirty buildup on their palms, despite the care plan indicating the need for hand hygiene and the use of hand protectors. Resident #33, who requires limited assistance with bathing, reported not receiving scheduled showers due to staff availability, missing two showers in a 30-day period. Resident #36, who requires extensive assistance with dressing, was found in their nightgown for three consecutive days, with their call light out of reach, indicating a lack of assistance in dressing and potential neglect in responding to their needs. The facility's policy states that residents should receive care to maintain or improve their ability to carry out ADLs, including grooming and personal hygiene, which was not adhered to in these cases.
Failure to Prevent Pressure Ulcer and Ensure Nutritional Care
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional care plans were updated and implemented for a resident. The resident, who was admitted with a diagnosis of pulmonary embolism and type 2 diabetes, developed a deep tissue pressure injury on the left heel a few weeks after admission. The wound nurse noted the injury as a blackened area measuring 2.55 cm by 2.57 cm, and the resident experienced pain during treatment. Despite the resident's alertness and orientation, the facility did not have any wounds indicated in the admission diagnosis, and the care plan was only revised on the day the state survey began. The resident experienced a significant weight loss of 10 pounds, or 9.13%, within approximately three weeks of admission. The facility's dietary management failed to consistently provide the prescribed nutritional interventions, such as protein shakes and cottage cheese, which were intended to aid in wound healing. The resident and their significant other reported inconsistencies in receiving the prescribed nutritional supplements and meals that were not aligned with the resident's dietary needs for diabetes and wound healing. Interviews with the dietary manager and registered dietician revealed a lack of awareness and follow-up regarding the resident's nutritional needs and preferences. The dietary manager admitted to not being aware of the resident's complaints and the registered dietician acknowledged the need for better monitoring of the resident's protein intake. The facility's wound policy aimed to identify residents at risk for skin alterations and implement specific interventions, but these measures were not effectively executed for the resident in question.
Failure to Apply Palm Protectors for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain or improve their range of motion, specifically by not applying bilateral palm protectors as required. Resident #21, who was admitted on 8/14/2020, was observed multiple times over two days without the necessary palm protectors on their hands, despite having contracted hands. The resident's care plan, as noted in the Kardex, specified that bilateral hand protectors should be worn during the day after hand hygiene and removed at night with skin checks for redness. The Therapy Director (TD) confirmed that Resident #21 had been on therapy with a discharge recommendation for palm protectors to be worn during the day. During an observation with the TD, the palm protectors were found in the resident's nightstand drawer, not in use. The TD cleaned the resident's hands, performed nail care, and applied the palm protectors. An instruction photo in the resident's closet showed how the palm protectors should be placed, and the TD stated that staff had been educated on their application.
Improper Storage of Narcotics During Medication Administration
Penalty
Summary
The facility failed to properly store narcotics for a resident during a medication administration task. On the morning of July 16, Nurse B prepared morning medications for a resident, including a Norco 5/325 tablet and a Pregabalin 150 mg tablet, and placed them in a clear medication cup. When the resident requested to take the medications later, Nurse B capped the cup, wrote the room number on it, and placed it in the top drawer of the medication cart instead of following proper storage procedures for narcotics. Later, Nurse B retrieved the medication cup from the drawer, counted the medications, and administered them to the resident. When questioned about the counting, Nurse B explained it was because the medications had been placed in the drawer. The Director of Nursing was informed of the incident and acknowledged that Nurse B should not have stored the narcotics in the drawer. The facility's Controlled Substances Policy states that medications not given should be destroyed and not returned to the container, indicating a breach of protocol in this instance.
Failure to Honor Dietary Preferences and Provide Palatable Meals
Penalty
Summary
The facility failed to honor a resident's food preferences and provide palatable meals, leading to significant weight loss and potential health risks. The resident, who was on a Controlled Carbohydrate Diet and No Added Salt diet, reported dissatisfaction with the meals provided, which were high in carbohydrates and sugar, contrary to her dietary needs for managing Type 2 Diabetes. Despite her preferences being documented, the meals served did not align with her dietary restrictions or personal likes, such as the inclusion of white bread and sugar cookies, and the absence of requested items like strawberries and cottage cheese. The resident's significant other corroborated her complaints, noting that he often had to bring fresh fruits from home because the facility did not provide them. During a meal observation, the resident's lunch tray contained items she disliked and were inappropriate for her dietary needs, such as a thick slice of white bread and a sugar cookie. The resident expressed frustration over the facility's failure to follow her documented preferences, which contributed to her reduced food intake and subsequent weight loss. Interviews with the Dietary Manager and Registered Dietician revealed a lack of awareness regarding the resident's unmet preferences and inconsistent provision of protein drinks. The facility's policies on therapeutic diets and food preferences were not effectively implemented, as evidenced by the resident's documented weight loss of 10 pounds over three weeks. The care plan included interventions to monitor for signs of malnutrition and honor food preferences, but these were not adequately followed, resulting in the deficiency.
Deficiency in Hospice Service Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of progress notes and assessments in the resident's medical record. During an observation, the resident was found grimacing and uncomfortable, and although the resident was under hospice care, the unit nurse had not notified the hospice agency about the resident's symptoms of nausea and vomiting. The hospice services binder for the resident lacked progress notes, a facility communication log, and follow-up documentation after a certain date, indicating ineffective communication and collaboration between the facility and hospice services. The hospice services binder contained minimal documentation and lacked details of services provided to the resident. The hospice staff's visits were not clearly documented, and there was a delay in scanning hospice progress notes into the facility's electronic medical record (EMR). The Director of Nursing acknowledged the communication gap and the delay in documentation submission. The hospice RN confirmed that the information in the resident's binder was outdated and that progress notes were sent via fax to the facility, which then scanned them into the EMR. Additionally, there were discrepancies in the administration of Morphine Sulfate, with doses given at intervals shorter than prescribed. The medication administration record showed multiple instances where the medication was administered less than the required six-hour interval. There were no noted changes in the prescribed order from any medical personnel regarding the dosages and frequency of administering the medication. The facility's policy specified that it is the hospice's responsibility to manage the resident's care related to the terminal illness, but the lack of proper documentation and communication led to potential unmet needs and suffering for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) in several rooms, leading to potential cross-contamination and spread of infections. On multiple occasions, staff members were observed not wearing the required Personal Protective Equipment (PPE) in EBP rooms. For instance, a nurse was seen sitting on a resident's bed without any PPE, and a CNA was caring for a resident who had an incontinent episode while only wearing gloves, without a gown to protect their uniform. These actions were contrary to the physician's order for enhanced barrier precautions, which required both gloves and gowns prior to high-contact care activities. Additionally, a housekeeper was observed cleaning the toilet and floor in an EBP room without wearing a gown, which is necessary to prevent contamination of their uniform. The facility's policy, based on CDC recommendations, mandates the use of gowns and gloves to protect residents and staff from hard-to-treat infections. Despite the presence of signs indicating the need for enhanced precautions, staff failed to adhere to these guidelines, as evidenced by the observations and record reviews conducted during the survey.
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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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