Huron County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Bad Axe, Michigan.
- Location
- 1116 South Van Dyke Road, Bad Axe, Michigan 48413
- CMS Provider Number
- 235028
- Inspections on file
- 21
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Huron County Medical Care Facility during CMS and state inspections, most recent first.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
A resident admitted with acute respiratory failure, heart failure, COPD, and an infection requiring IV antibiotics did not have a baseline care plan developed within 48 hours to address their IV catheter and infection needs. Staff confirmed the omission, and review of the care plan showed it lacked required interventions for these conditions.
A resident with a urinary catheter was observed on two occasions with the catheter tubing and bag in contact with the floor while in a wheelchair. The resident, who had impaired cognition and required extensive assistance, had the catheter tubing exposed and dragging on the floor in both the dining room and hallway, contrary to infection control guidelines.
The facility did not ensure that physician's orders for oxygen administration included specific flow rates for two residents with respiratory conditions. Both residents received oxygen therapy based on orders that only directed staff to maintain oxygen saturation above 90%, without specifying the liters per minute. The DON confirmed that none of the oxygen orders included flow rates, and facility policy requiring this information was not followed.
A resident with dementia and behavioral disturbances was not treated with dignity when a CNA argued with her, removed her bingo chips, and forcefully pushed her in a wheelchair out of the activity room after a group activity. The staff did not follow the resident's care plan, which required individualized support and reassurance, resulting in the resident's distress and confusion.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks. Observations included soiled floors, improper storage of food items, and incomplete cleaning documentation. Additionally, sanitizing solutions were found ineffective, and temperature control for food items was inadequate, with milk stored at unsafe temperatures.
The facility failed to implement effective infection control measures, as staff did not adhere to hand hygiene and PPE protocols in isolation rooms. There was inadequate tracking of resident and employee illnesses, and a resident's urinary catheter bag was improperly placed on the floor. Staff inconsistently followed Enhanced Barrier Precautions, compromising resident safety.
The facility failed to maintain resident dignity by not responding to call lights promptly, leading to residents soiling themselves. Additionally, the closure of the Bingo store and the unprepared outdoor patio further contributed to residents' dissatisfaction and feelings of neglect.
The facility failed to address multiple concerns raised by residents, including unresponsive call lights, unsatisfactory food service, an unusable outdoor patio, and the removal of the Bingo store. Despite repeated mentions in Resident Council meetings, the facility did not take effective action to resolve these issues, leading to resident frustration and dissatisfaction.
A facility failed to develop a baseline care plan for falls within 48 hours for a resident with epilepsy, depression, and profound intellectual disabilities, who was assessed as high risk for falls. The care plan was delayed, and the resident sustained falls after admission. The facility's policy requires such plans to be developed within 48 hours, including interventions for fall risks.
A resident with Alzheimer's Dementia and severe cognitive loss was admitted to a facility without a comprehensive, resident-centered care plan. Despite being assigned a 1:1 staff member for supervision due to wandering behavior, the care plans lacked specific interventions for the resident's likes and dislikes. The care plans were developed weeks after admission and did not include person-centered interventions, contrary to the facility's policy.
A resident with epilepsy, depression, and profound intellectual disabilities experienced two falls in the facility. After the second fall, the care plan was not updated until five days later, contrary to the facility's policy. The Restorative Nurse acknowledged the delay, which resulted in a deficiency.
A resident with severe cognitive impairment developed a facility-acquired pressure injury on the heel, suspected to be caused by wheelchair foot pedals. Despite interventions, the facility failed to ensure timely nutritional evaluation, with the dietitian assessing the resident nearly a month after the injury. The facility's policy required prompt referral to the dietitian, which was not followed.
The facility failed to ensure proper respiratory care and equipment management for residents. A resident with COPD was found with an empty oxygen tank, and another resident's CPAP machine was improperly maintained with undated distilled water and a water chamber not emptied daily. Additionally, distilled water for a CPAP machine was improperly stored on the floor. Staff acknowledged the need for better monitoring and documentation.
A resident with severe cognitive loss was treated with Bactrim for a suspected UTI without appropriate lab tests to confirm the infection or determine antibiotic effectiveness. The facility's antibiotic stewardship policy was not followed, as necessary urinalysis and culture and sensitivity tests were not conducted, and the resident's care plan was outdated.
A resident did not receive the 2023/2024 influenza vaccine despite having consented, due to the facility's policy of not administering flu vaccines after March 31st. The resident was initially unwell but later received a COVID-19 booster, indicating they were healthy enough for vaccinations. The DON could not provide CDC documentation supporting the facility's policy.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report. No information is given regarding the medical history or condition of any residents at the time of the deficiency.
Failure to Develop Baseline Care Plan for IV Therapy and Infection
Penalty
Summary
The facility failed to develop a baseline care plan that addressed the immediate needs of a resident within 48 hours of admission, as required by facility policy. The resident was admitted with acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease, and was observed receiving oxygen therapy. The resident also had a midline IV catheter for antibiotic administration due to an infection. During interviews, the resident reported issues with the IV catheter, including needing to leave the facility for a replacement, and confirmed ongoing antibiotic treatment. Upon review, it was found that the baseline care plan did not include interventions or care planning for the IV catheter or the infection. The Unit Manager and MDS Nurse both confirmed that the care plan lacked documentation and planning for these critical needs, despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission and to include all necessary instructions for person-centered care, including special needs such as IV therapy. The deficiency was identified through observation, interview, and record review.
Catheter Bag and Tubing Found Resting on Floor
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed on two separate occasions with the catheter tubing and bag in contact with the floor. On the first occasion, the resident was in the dining room in a wheelchair, with the catheter bag hooked under the wheelchair and approximately eight inches of tubing resting on the floor. The catheter bag cover was also observed touching the floor. On the second occasion, the resident was again in their wheelchair, and the catheter tubing was seen exposed and dragging on the floor as the resident was assisted through the hallway and positioned in the dining room. The resident involved had a history of cancer, anemia, and obstructive uropathy, with severely impaired cognition and required extensive assistance with all activities of daily living. The improper securing of the catheter bag and tubing, resulting in contact with the floor, was directly observed by staff and reported to facility management. The report references CDC and other guidelines that state catheter bags should not be placed on the floor due to the risk of contamination.
Failure to Specify Oxygen Flow Rates in Physician Orders for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen administration included specific flow rates for two residents who required respiratory care. For one resident with diagnoses including pulmonary fibrosis, COPD, acute respiratory failure, and interstitial pulmonary disease, observation revealed oxygen being administered at 6 liters per minute, but the physician's order only directed staff to maintain oxygen saturation at or above 90% without specifying a flow rate. The Director of Nursing confirmed that none of the oxygen orders for residents included flow rates, and staff would not know the correct rate without checking previous charting. A second resident, admitted with acute respiratory failure with hypoxia, heart failure, and COPD, was observed receiving oxygen via nasal cannula, with the flow rate fluctuating between 2 and 4 liters per minute as documented in the treatment record. However, the physician's order for this resident also lacked a specified flow rate, only instructing to maintain oxygen saturation at or above 90%. The DON acknowledged that the oxygen order should have included the liters per minute for administration. Facility policy requires physician orders for oxygen to include flow rate, route, and duration, but this was not followed for either resident.
Failure to Treat Resident with Dignity During Activity
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and treat a resident with dignity during and after a group activity. The resident, who had diagnoses including dementia, stroke, and behavioral disturbances, was observed to have severely impaired cognition and required assistance with activities of daily living. The care plan specified that staff should provide activities the resident enjoys, avoid interrupting her during activities, and offer reassurance, as she becomes confused and frustrated if contradicted. During a bingo activity, the resident became upset, insisting that her bingo chips, purse, and coat had been taken. Staff statements and video surveillance confirmed that a CNA argued with the resident, removed bingo chips from her hands, and forcefully pushed her in her wheelchair out of the activity room. The CNA was observed raising her voice, physically moving the resident's hands from the table, and quickly pushing her out of the room, despite offers of assistance from other staff. The incident resulted in the resident displaying distress, calling out, and slamming her hand on the table. Multiple staff interviews corroborated that the CNA's actions were loud, forceful, and did not align with the resident's care plan, which emphasized dignity and individualized support. The resident was later found in another area, still expressing confusion and distress about her belongings. Documentation in the medical record noted previous behavioral issues during activities, but the care plan required staff to manage these behaviors with patience and reassurance, which was not observed during this incident.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During an inspection, the surveyor observed several issues, including a soiled floor with visible debris in the walk-in freezer and cooler, broken eggshells, and a container of heavy whipping cream on the floor. The Dietary Manager acknowledged the issues but attributed them to the stock person's schedule and recent mopping. Additionally, there was a heavy accumulation of ice buildup on the refrigerant lines in the walk-in cooler, which the Dietary Manager was unaware of. Further observations revealed unsanitary conditions in the second floor's kitchenette, where a container of liquid butter was stored improperly, leading to a heavy coating of butter on the cabinet. The Dietary Manager was unaware of this issue and noted that the butter should have been in a squeeze bottle. The cleaning checklist for the kitchen was only partially filled out, indicating incomplete documentation of daily cleaning tasks. The Dietary Manager described it as a work in progress. The facility also failed to maintain proper sanitization and temperature control. A sanitizing bucket in the third floor's kitchenette was found to have a concentration of zero, and the temperature of the chemical solution was below the required level. The Dietary Manager admitted the solution might have been from the morning and needed to be remade. Additionally, a half-gallon of milk was found at an unsafe temperature, and the Dietary Manager acknowledged it should be discarded. The Regional Dietary Supervisor suggested ordering personal containers of milk to maintain proper temperature control.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene and personal protective equipment (PPE) protocols. On several occasions, staff members entered a room designated for contact and droplet isolation without performing hand hygiene or donning the required PPE, such as gowns and masks. This was despite clear signage indicating the need for such precautions. Additionally, there was no trash receptacle available for the disposal of PPE, leading staff to use a bathroom trash can instead. The facility also lacked a comprehensive system for tracking resident and employee illnesses. During a review of the infection control line listing, it was found that there was no mapping of infections, and the documentation for employee illnesses was inadequate. The Infection Control Nurse and Director of Nursing admitted that they relied on call-in slips to monitor employee illnesses but did not have a formal tracking system in place. This lack of documentation and follow-up could hinder the facility's ability to identify and respond to potential outbreaks. Specific deficiencies were noted in the care of Resident #20, who had a urinary catheter bag improperly placed on the floor, increasing the risk of contamination. The resident, who had multiple health conditions including acute respiratory failure and pneumonia, was under Enhanced Barrier Precautions. However, staff did not consistently wear PPE when changing bed linens, contrary to the instructions posted on the resident's door. This inconsistency in following infection control protocols further highlights the facility's failure to maintain a safe environment for its residents.
Deficiencies in Resident Dignity and Facility Maintenance
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by several issues reported by a group of residents. Residents on the 2nd and 3rd floors expressed that during the night shift, their call lights were not answered in a timely manner. Staff members would sometimes turn off the call lights without addressing the residents' needs, leading to situations where residents were left to soil themselves due to lack of assistance. This delay in response time was noted to sometimes extend up to an hour, despite the call light system being designed to alert a supervisor if unanswered for too long. Additionally, residents reported dissatisfaction with the closure of the Bingo store, which had been a source of enjoyment and provided them with items they needed. The store was removed to repurpose the space, with promises of reopening it elsewhere in the facility, but no solution had been provided for several months. Furthermore, the outdoor patio was not maintained, with tables and chairs not set up and a lack of necessary equipment to care for the resident's garden. This neglect prevented residents from using the patio for activities and visits, contributing to their feelings of disrespect and discouragement.
Facility Fails to Address Resident Concerns
Penalty
Summary
The facility failed to address multiple concerns raised by the Resident Council and a specific resident, leading to frustration and dissatisfaction among the residents. The issues included call lights not being answered promptly, food preferences not being accommodated, cold food being served, the inability to use the outdoor patio, and the removal of the Bingo store. Despite repeated mentions of these issues in Resident Council meetings, the facility did not take effective action to resolve them. Residents reported that call lights were often turned off without assistance being provided, leading to situations where residents soiled themselves due to lack of timely help. The Dietary Manager was aware of the complaints about cold food and the quality of evening meals but had not implemented any interventions to address these concerns. Additionally, the facility's failure to accommodate specific dietary needs, such as gluten-free options, further contributed to resident dissatisfaction. The outdoor patio remained unprepared for use, with tables and chairs not set up and the garden hose lacking a nozzle, preventing residents from enjoying the space or entertaining visitors. The Bingo store, which was a source of enjoyment and necessity for residents, was closed for remodeling and had not been reopened, despite promises to do so. The facility's inaction on these matters, despite being aware of them, highlights a significant deficiency in addressing resident grievances and maintaining their quality of life.
Failure to Develop Timely Baseline Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a baseline care plan for falls for a resident within the required 48-hour timeframe following admission. The resident, who is [AGE] years old, was admitted with diagnoses including epilepsy, depression, and profound intellectual disabilities. Despite being assessed as a high risk for falls with a score of 22 on 05/14/24, the baseline care plan addressing falls was not implemented until 05/17/24. This delay in creating a care plan was confirmed by the Minimum Data Set Nurse, who acknowledged that the baseline care plan should have been completed within 48 hours of admission and should have addressed fall risks. The resident sustained falls on 05/22/24 and 07/04/24, indicating that the lack of a timely baseline care plan may have contributed to these incidents. The facility's policy on baseline care plans, reviewed in February 2024, mandates that such plans be developed within 48 hours of admission and include interventions for health and safety concerns, such as fall risks. The failure to adhere to this policy resulted in an incomplete baseline care plan for the resident, potentially compromising their safety and care.
Failure to Develop Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered comprehensive care plan for a resident with Alzheimer's Dementia and other medical conditions, including urinary retention, glaucoma, anxiety, depression, and severe cognitive loss. The resident, who was admitted to the facility with a BIMS score of 3/15, was observed wandering non-stop in the hallways and attempting to enter other residents' rooms. Despite being assigned a 1:1 staff member for supervision, the resident's care plan lacked specific interventions to address his likes and dislikes, and the care plans were not developed until several weeks after his admission. Interviews with facility staff revealed that the resident had been wandering since admission and had been transferred to a psychiatric hospital for medication stabilization before returning to the facility. The care plans, including those for mood, mobility, safety, bladder management, pain, visual function, and behavior, were all dated after the resident's return from the hospital, and none included person-centered interventions. The facility's policy on comprehensive care plans emphasizes the importance of developing a person-centered care plan with measurable objectives and time frames, but this was not adhered to in the case of this resident.
Delayed Care Plan Update After Resident Falls
Penalty
Summary
The facility failed to update the care plan in a timely manner for a resident who experienced falls, resulting in a deficiency. The resident, who has epilepsy, depression, and profound intellectual disabilities, was admitted to the facility and had a history of falls. On two occasions, the resident sustained falls, one on 05/22/24 and another on 07/04/24. After the first fall, a new intervention was implemented by placing a perimeter mattress on the bed. Following the second fall, the bed was placed in the lowest position as a new intervention. However, the care plan was not updated until five days after the second fall, which was not in accordance with the facility's policy. The facility's Fall Prevention Program policy requires that the interdisciplinary team review falls and evaluate the need for further interventions promptly. Despite this, the care plan for the resident was not revised until 07/09/24, five days after the fall on 07/04/24. The Restorative Nurse responsible for updating the care plan acknowledged that the update should have occurred sooner and was unsure how the delay happened. This delay in updating the care plan after the fall incident led to the deficiency noted by the surveyors.
Failure to Prevent Pressure Injury and Ensure Timely Nutritional Evaluation
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional evaluation for a resident with a suspected deep tissue injury (SDTI) on the left heel. The resident, who had severe cognitive impairment and was dependent on a wheelchair, developed a fluid-filled blister with a purple center on the heel, which was later identified as a deep tissue injury. The wound care nurse confirmed that the injury was facility-acquired and suspected it was caused by the foot pedals on the resident's wheelchair. Despite interventions such as padding the foot pedals and using pressure-relieving boots, the facility did not ensure timely nutritional evaluation following the injury. The resident's medical record showed a delay in nutritional evaluation, with the next assessment occurring nearly a month after the injury was identified. The dietitian was not notified promptly about the pressure injury, and there was no record of contact regarding the wound. Although the resident had a good appetite and was consuming protein Jello, the dietitian only evaluated the resident's nutritional needs a month after the injury's development. The facility's policy required nursing staff to refer residents with pressure injuries to the dietitian for nutritional review, but this was not done in a timely manner. Interviews with the wound care nurse and dietitian revealed that the interdisciplinary team, which included the dietitian, reviewed resident wounds weekly. However, the dietitian did not have a record of being contacted about the resident's injury and stated that typically, she would see residents immediately after being informed of such injuries. The facility's protocol required a nutrition risk assessment and dietitian notification within 72 hours of identifying a new pressure injury, which was not adhered to in this case.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for Resident #58, who was observed with an empty oxygen tank while using a nasal cannula. The resident, diagnosed with chronic obstructive pulmonary disease, heart disease, and anxiety disorder, was found propelling herself in her wheelchair with the oxygen tank indicator on red, suggesting it was out of oxygen. Despite wearing the nasal cannula, the resident did not feel any oxygen flow, and there was no sound from the cannula. A CNA confirmed the tank was empty and replaced it, while a nurse monitored the resident's oxygen saturation, which was between 92% and 94%. The CNA admitted to not checking the resident's oxygen tank at the start of the shift, and the Unit Manager acknowledged the need for more frequent checks when tanks are low. In another instance, the facility did not properly manage the CPAP machine and distilled water for Resident #70, who had diagnoses including dementia, insomnia, and sleep apnea. The CPAP machine was found with a partially filled water chamber and an undated, partially used gallon of distilled water on the bedside table. The Director of Nursing and Unit Manager confirmed that distilled water should be dated upon opening, and the water chamber should be emptied and dried daily, although there were no documented orders for this procedure. The CPAP machine was later removed as the resident had been refusing its use, and it was discontinued prior to the observation. Additionally, the facility failed to ensure proper storage of distilled water for a CPAP machine in another resident's room. The water was stored on the floor, contrary to the facility's expectations, and the Unit Manager noted that the resident had moved it there. The Director of Nursing indicated that the facility's policy did not require dating the distilled water, and the CPAP/BiPAP policy was requested but not provided by the facility.
Failure to Follow Standards for Antibiotic Use and Laboratory Testing
Penalty
Summary
The facility failed to adhere to standards of practice for laboratory testing and antibiotic use for a resident with a history of urinary tract infections. The resident, who had severe cognitive loss and required assistance with all care, was treated with the antibiotic Bactrim for a suspected urinary tract infection without appropriate laboratory tests to confirm the infection or determine the effectiveness of the antibiotic. The Infection Prevention and Control Nurse was unable to provide laboratory reports for urinalysis and culture and sensitivity tests, which are necessary to identify the infection and the most effective treatment. The physician's orders indicated that Bactrim was prescribed for ten days, but the documentation lacked evidence of a culture result or sufficient rationale for the antibiotic treatment. The urinalysis results showed potential contamination, and no culture and sensitivity reports were available to confirm an infectious organism or antibiotic sensitivity. The facility's policy on antibiotic stewardship was not followed, as laboratory testing was not conducted in accordance with current standards of practice. Additionally, the resident's bladder management care plan had not been updated to reflect the recent antibiotic treatment.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to administer the 2023/2024 influenza vaccine to a resident, despite the resident having given consent for the vaccination on May 13, 2024. A review of the resident's immunization records on July 10, 2024, revealed no documentation of the influenza vaccine being administered. The resident had been admitted with a gastrointestinal infection and was on antibiotics intermittently, which the Director of Nursing (DON) cited as the reason for not administering the vaccine initially. However, the resident later received a COVID-19 booster on May 31, 2024, indicating they were healthy enough for vaccinations at that time. The DON stated that the facility's medical director does not allow flu vaccinations after March 31st, despite the Centers for Disease Control and Prevention (CDC) guidelines indicating that flu vaccines do not expire until June 30th and can still be administered in the spring. When asked to provide CDC documentation supporting the medical director's policy, the DON was unable to find any such guidance. This discrepancy between the facility's policy and CDC guidelines contributed to the failure to vaccinate the resident against influenza.
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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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