Iron County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal Falls, Michigan.
- Location
- 1523 U.s. Highway 2, Crystal Falls, Michigan 49920
- CMS Provider Number
- 235257
- Inspections on file
- 24
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Iron County Medical Care Facility during CMS and state inspections, most recent first.
Surveyors found that several doors equipped with 15-second delayed egress hardware lacked required signage and did not function as intended, with some doors failing to initiate the irreversible opening sequence and others bypassing it entirely. These deficiencies were confirmed during testing and observation with the Acting Maintenance Director.
Surveyors observed a large amount of cigarette butts scattered throughout the smoking area and in the grass, indicating that required smoking regulations and proper disposal methods, such as the use of approved ashtrays and metal containers, were not being followed. This was confirmed by the Acting Maintenance Director.
Surveyors observed that the facility did not label the generator's above ground diesel fuel tank with an NFPA 704 placard in a visible location, as required by NFPA 30. This deficiency was confirmed by the Acting Maintenance Director and represents noncompliance with multiple NFPA standards.
Empty and full oxygen cylinders were found mixed together on a cart in the Cedar Wing oxygen storage room, rather than being properly segregated as required by NFPA 99. This was confirmed by the Acting Maintenance Director during the survey.
The facility did not provide documentation that the kitchen hood fire suppression system in one wing had received the required hydrostatic testing, as confirmed by the Acting Maintenance Director during record review. This deficiency could impact up to 30 occupants in the event of a fire emergency.
An exercise bike in the inpatient gym area was found plugged into an extension cord, contrary to NFPA 99 and NFPA 70 standards for electrical safety. The improper use of the extension cord was confirmed by the Acting Maintenance Director during the survey.
Surveyors identified a medication error rate of 13.33% after observing multiple instances where nurses crushed potassium chloride ER capsules against physician orders, allowed a resident to chew a capsule without water, failed to document or notify the physician about medication administration issues, and did not shake liquid medication before administration. These actions were not in accordance with facility policy or physician instructions.
Staff failed to perform hand hygiene between resident rooms during water pass and while providing catheter care, resulting in the use of contaminated gloves to touch environmental surfaces and resident items. Staff acknowledged not following hand hygiene protocols, and the DON was informed of the risk for cross-contamination.
The facility did not ensure that monthly Medication Regimen Reviews were reviewed, addressed by a physician, or maintained in residents' clinical records. For several residents with complex medical conditions, pharmacy reports were missing for multiple months, and facility leadership acknowledged that there was no process in place to ensure pharmacy consults were addressed or documented as required.
A resident with multiple diagnoses received both vitamin D2 and D3 concurrently after a physician accepted a pharmacy recommendation to switch formulations, but the original vitamin D2 order was not discontinued. This resulted in duplicate weekly administration and excessive dosing, which was not identified due to a missed step in the medication order review process.
A resident with COPD, anxiety, and dementia was given supplemental oxygen at a higher flow rate than ordered by the physician, with no documented assessment or physician notification to support the change. The oxygen tubing was not replaced according to facility protocol, and nebulizer equipment was not cleaned or stored in a sanitary manner as required. Staff interviews and record reviews confirmed these failures to follow physician orders and facility policies for respiratory care.
The facility's QAPI committee failed to meet quarterly with all required members, with key personnel such as the Medical Director, DON, IP, and NHA frequently absent. This inconsistency placed all 115 residents at risk for quality care concerns.
A resident did not receive a dose of hydrocodone-acetaminophen that was signed out by an RN, leading to an investigation. The RN had a history of careless documentation and suspicious behavior, including increased PRN administration. The RN refused a drug test and was terminated as per facility policy.
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. One resident was found with facial fractures, and another with multiple fractures, but neither incident was reported as required by facility policy.
The facility failed to complete an investigation for an incident where a resident with severe cognitive impairment and multiple medical conditions was found on the floor with fractures. Despite the severity, the investigation was not completed as required by the facility's procedures.
The facility failed to assess and monitor pressure injuries for a resident, leading to inadequate care. The resident had a pressure injury on the left gluteal area and a deep tissue injury on the left heel, but there was no proper documentation or treatment. A stage II pressure injury on the sacrum was also not documented or treated according to the facility's policies. The DON and staff were unaware of the current status of these injuries, and the required weekly skin assessments were not completed.
The facility failed to report PBJ information to CMS, resulting in inaccurate staffing level reports. A review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024 revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day. An RN responsible for PBJ data submission confirmed that the facility missed the submission deadline, potentially affecting all 115 residents.
Noncompliance with Delayed Egress Door Requirements
Penalty
Summary
Surveyors observed that several doors in required means of egress were equipped with 15-second delayed egress hardware but did not meet the requirements set forth by NFPA 101. Specifically, the door to the main nurses station from Willow Wing and Door 12 were missing the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." Additionally, the Birch Wing Alcove exit, Door 17, and other doors failed to initiate the irreversible opening sequence when tested multiple times, indicating that the delayed egress function was not operating as intended. In contrast, Door 9 and Door 8, while appropriately signed, immediately opened and bypassed the irreversible opening sequence upon testing, further demonstrating noncompliance with the required delayed egress operation. These deficiencies were confirmed through direct observation and testing by the surveyor, with the Acting Maintenance Director present at the time. The report does not mention any specific residents or their medical conditions in relation to these findings. The focus of the deficiency is on the improper installation, signage, and functioning of delayed egress hardware on multiple doors, which did not comply with the standards for special locking arrangements as required by NFPA 101.
Failure to Enforce Smoking Regulations and Proper Disposal of Cigarette Butts
Penalty
Summary
The facility failed to ensure that smoking regulations were fully implemented and adhered to as required by regulatory standards. During an exterior tour of the building, a large number of cigarette butts were observed scattered on the ground throughout the designated smoking area and in the surrounding grass. This observation was confirmed by the Acting Maintenance Director at the time of discovery. The presence of cigarette butts indicates that proper disposal methods, such as the use of metal containers with self-closing covers and noncombustible ashtrays, were not being utilized as required in areas where smoking is permitted.
Failure to Label Generator Fuel Tank with Required NFPA 704 Placard
Penalty
Summary
The facility failed to comply with requirements for labeling the generator's above ground diesel fuel tank with an NFPA 704 placard. During an observation on April 23, 2025, it was noted that the fuel tank was not marked with the required placard in a location visible upon approach, as mandated by NFPA 30, 21.7.2.1. This deficiency was identified during a survey and confirmed by the Acting Maintenance Director at the time of discovery. The report specifies that this failure to label the fuel tank properly is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. The deficiency could potentially affect all occupants in the event of a fire, as the lack of proper labeling may hinder emergency response or safety procedures. No specific residents or patient conditions are mentioned in the report.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure proper storage of nonflammable gas cylinders in accordance with NFPA 99 requirements. During an observation in the Cedar Wing oxygen storage room, it was found that empty oxygen cylinders were not segregated from full oxygen cylinders. Specifically, 38 cylinders were observed mixed together on a cart, rather than being separated as required by regulations. This deficiency was confirmed at the time of discovery by the Acting Maintenance Director. The report does not mention any specific patients or their medical conditions in relation to this deficiency. The focus of the finding is on the improper storage practice of oxygen cylinders, which did not meet the established standards for gas equipment storage.
Failure to Complete Required Hydrostatic Testing of Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96 standards. During a record review, it was found that the kitchen hood fire suppression system in the Cedar Wing had not undergone the required hydrostatic testing, as the two most recent inspection records did not show evidence of this testing being completed. No documentation was provided by the end of the survey to confirm that the hydrostatic test had been performed. This deficiency was confirmed by the Acting Maintenance Director at the time of the record review. This lapse could affect up to 30 occupants in the event of a fire emergency, as noted in the findings.
Noncompliant Use of Extension Cord for Exercise Equipment in Patient Care Area
Penalty
Summary
A deficiency was identified when, during an observation in the inpatient gym area, an exercise bike was found plugged into an extension cord. This setup did not comply with NFPA 99 and NFPA 70 requirements regarding the use of power strips and extension cords for electrical equipment in patient care areas. The observation was confirmed by the Acting Maintenance Director at the time. The report specifies that extension cords are not to be used as a substitute for fixed wiring and must be removed immediately after temporary use, which was not adhered to in this instance. No additional details about the specific occupant affected, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 13.33% based on four medication errors out of thirty opportunities. Surveyors observed multiple instances where nursing staff did not follow physician orders or facility policy during medication administration. For example, a registered nurse crushed potassium chloride extended-release capsules for two residents, despite clear physician instructions and labeling that the medication should not be crushed. In both cases, there were no physician orders or care plan indications permitting the medications to be crushed. Another resident was observed chewing a potassium chloride capsule, which was not administered with water as required by FDA guidelines and facility policy. The nurse did not document the resident's difficulty swallowing the medication, nor was the physician notified that the resident did not receive the full prescribed dose or that a change to a liquid form might be needed. Additionally, a nurse failed to shake a bottle of senna oral syrup before administration and combined the unshaken liquid with other crushed medications in coffee, again without a physician's order or care plan direction to do so. The Director of Nursing confirmed that medications labeled as "do not crush" should not be altered without a physician's order, and that proper procedures for medication administration, documentation, and disposal were not followed in these cases. Facility policy also requires hand hygiene between residents, destruction of unused medications, and notification of the physician if a resident does not take medications as prescribed, none of which were consistently observed during the survey.
Plan Of Correction
The facility will develop a plan to maintain a medication error rate of 5% or less. For Resident #95, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #8, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #70, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #23, a review of bowel movements was completed by DON to assure that the resident did not have any unusual increased or decreased frequency of bowel movements. The resident was also monitored through daily nursing notes and CNA task documentation. ADON identified all residents who receive potassium and all who receive crushed, opened, or modified medications that had the potential to be affected. Immediate 1:1 education was given to nurses in the facility on Do Not Crush medications. DON and ADON reviewed the Medication Administration Policy and updated the Oral Crushed Medication section to reflect that a physician order is needed to crush any medication and to administer multiple crushed medications together. DON and ADON completed a Root Cause Analysis (RCA). They created a Relias module and posttest reinforcing the following: - If a pill is dropped onto the cart or floor, place it in the Drug Buster and retrieve a new pill to administer. - Shake well to mix suspensions. - Crushed medications require a Physician order to crush. - Potassium orders require a DO NOT CRUSH order but may be opened and sprinkled. - If a resident refuses medications, document in EHR and notify the Charge Nurse. - If medication has been prepared and then refused, destroy it in the Drug Buster. - Perform hand hygiene prior to administering medication. - Perform hand hygiene after medication administration. - If a resident is displaying difficulty with any medication (e.g., taste, form, size), notify the physician. - For employees who are casual/student status, on vacation, or on leave of absence (LOA), training will be completed before or during their next scheduled shift. DON provided a full list of residents who receive crushed medications to DNP for review and to write an order for long-acting medications indicating: 1) Do Not Crush OR 2) Do Not Crush, but may open and sprinkle and combine OR 3) May crush and Do NOT combine OR 4) May crush and combine Once orders are processed, MDS will update the Care Plan to reflect this. DON created a new form: Refusal of Medication/Medication Change Request Form, for charge nurses (notified by neighborhood nurses) to fill out for residents who may require a change in medication for any reason. Completed forms will be given to DNP for any necessary action. DON verified that audits are performed monthly by the pharmacy consultant for any residents who should have an order stating Do Not Crush. The Omniviews DO NOT CRUSH medication list was added to all units' medication information binders, placed at the north side nurses' station, and given to Administrative Medical Assistants. To ensure the policy review and changes are followed, DON/ADON or designee will randomly audit a medication pass with a focus on: - Medications are not being altered or combined without an order - No prepared medication stored in the medication cart - Performing hand hygiene - Medication disposed of appropriately if contaminated or refused - Shaking of liquid medications - Notification to the charge nurse for medication refusal Audits will occur on two nurses weekly on each shift for one month, then one nurse on each shift weekly for two months, and then one nurse monthly on an ongoing basis to ensure compliance with facility guidelines. The pharmacy consultant will audit residents' orders monthly and ensure Do Not Crush orders are present for medications that should not be crushed, sending recommendations if an order is missing. The MDS coordinator or designee will conduct quarterly audits to verify that any resident on crushed, opened, modified, or combined medications has a corresponding intervention in their care plan. DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for three months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by DON to ensure compliance in accordance with the plan of correction. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Perform Hand Hygiene During Resident Care and Water Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during routine care activities, specifically during the distribution and collection of water mugs and during catheter care. Certified Nurse Aide (CNA) "A" was observed delivering fresh water and removing used water mugs from multiple residents' rooms without performing hand hygiene between rooms. CNA "A" admitted to not using hand sanitizer between rooms and acknowledged the importance of hand hygiene in preventing cross-contamination. During catheter care for a resident, CNA "O" and CNA "C" donned gloves as part of Enhanced Barrier Precautions. CNA "O" performed perineal care and, without removing contaminated gloves, touched environmental surfaces such as closet handles and retrieved a clean incontinence brief. The same contaminated gloves were used to change the resident's brief and assist with clothing and protective boots. CNA "O" acknowledged that hand hygiene and glove changes should have occurred after cleaning the resident's genitals and catheter tubing. A registered nurse confirmed that gloves should be removed and hand hygiene performed before touching other surfaces. The facility's hand hygiene policy requires staff to perform hand hygiene before donning gloves and immediately after removing them, emphasizing that glove use does not replace hand hygiene. The Director of Nursing was made aware of the observations and expressed understanding of the deficiency related to the failure to perform hand hygiene and the potential for cross-contamination within the facility.
Plan Of Correction
The facility will develop a plan to ensure hand hygiene will be performed during a fresh water pass and post catheter care. For resident #11, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #32, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #33, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #38, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #50, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #52, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #55, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. Housekeeping disinfected the high-touch surfaces in room. The DON/ADON and designees identify residents on Enhanced Barrier Precautions who were potentially affected. For any identified, the DON/ADON will monitor daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. Immediate 1:1 education was provided to Resident Assistants in the facility on proper hand hygiene protocol between residents when passing water jugs. All others were educated before or during their next working shift. DON and ADON completed policy reviews on the following: 1) Hand Hygiene Policy reviewed and updated to indicate when it's appropriate to perform hand hygiene: a. Perform Hand Hygiene before and after: i. Performing invasive procedures ii. Handling medications iii. Handling contaminated items iv. Contact with blood and body fluid, secretions, excretions, mucous membranes, etc v. Assisting with/providing personal care vi. Eating vii. Using the restroom viii. Sneezing, coughing, blowing or wiping nose. b. When in doubt, wash your hands. 2) Catheter Care Policy—updated to indicate it’s appropriate to remove gloves and perform hand hygiene after performing catheter care but before touching clean items. Then don new, clean gloves. 3) Drinking Water Distribution Policy—updated to indicate hand hygiene is to be performed before entering a resident’s room and after placing the empty jug on the cart. DON and ADON created an education module with posttest on Relias for: 1) All Resident Assistants on performing hand hygiene between resident rooms 2) All CNAs on when to perform hand hygiene after performing catheter care, but before touching clean items such as closet handle, clothing, or clean brief. Per facility policy, you are required to remove gloves, perform hand hygiene, and don new, clean gloves. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. To ensure compliance with hand hygiene after education, DON/ADON or designee will perform hand hygiene audits during a water pass 6x/week for 2 weeks, 4x/week x 2 weeks, then 2x weekly for two months. Audits for hand hygiene for residents on Enhanced Barrier Precautions will be completed by DON/ADON or designee with focus on reducing the risk for cross-contamination. Two audits weekly for 1 month, one audit weekly for 2 months. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Maintain and Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were properly reviewed, addressed by the physician, and maintained in the clinical records for four out of five residents reviewed. For multiple residents with complex medical histories, including dementia, diabetes, anxiety, depression, and other conditions, pharmacy reports documenting the MRR were missing for several months. The Director of Nursing (DON) was unable to locate these reports in the electronic medical record and acknowledged that she did not keep them as required. The DON also confirmed that there was no way to determine what recommendations the pharmacist had made, whether the medical director or nurse practitioner had agreed or disagreed with those recommendations, or if any rationale for decisions was documented. Interviews with facility leadership, including the DON and Nursing Home Administrator (NHA), revealed that there was no designated staff member ensuring that pharmacy consults were being addressed. The NHA admitted that the system for handling pharmacy consults was broken and deficient. Review of the facility's own policy confirmed that written communications from the pharmacist should become a permanent part of the resident's medical record, but this was not being followed. As a result, the facility was unable to demonstrate compliance with federal requirements for drug regimen review and documentation.
Plan Of Correction
For Resident #67, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #36, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #65, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #90, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. The DON/designee audited the EMR for all residents and identified those residents who did not have a DRR in April 2025. The DON notified the pharmacist that these reviews needed to be completed. DON and ADON had a phone conference with the pharmacy consultant about our process and how to correct it. To ensure the pharmacy recommendations are being answered according to policy, the process needs to come back to an in-house process instead of reports being sent electronically to an outside source, Theoria. DON and ADON met with the DNP about changing the processing of pharmacy consultation reports by bringing the process back internally instead of sending them to Theoria to process. The DNP was in agreement. On 4/21/2025, it was confirmed that the pharmacist would be at the facility in person on 4/24/2025 to meet and discuss survey findings and finalize the plan to bring the process back to an in-house process. On 4/24/2025, the DON and ADON met with the consulting pharmacist to review the Medication Regimen Review policy and discussed the new process as follows: 1) After receiving monthly pharmacy recommendations, the ADON will print and separate them for delivery as follows: a. Nursing will be handed the recommendations to be given to the Administrative Medical Assistant to initiate processing. b. The physician will be handed the recommendations to be reviewed and responded to by the DNP and/or medical director. c. GDRs — a meeting will be scheduled for the Behavior Team to review and give their recommendations to the DNP/medical director for review and response. 2) Once all recommendations have been reviewed and have a response, all reports will be given to the charge nurse for processing. 3) A copy of the summary of MRRs will be given to charge nurses to indicate orders they process. 4) Recommendations will then go to HIM to be scanned into the residents' medical records. 5) The DON/ADON will review the completion of recommendations weekly. On 4/25/2025, the current Pharmacy Consultation Reports from the pharmacist with new and outstanding recommendations were received. On 4/28/2025, the DON and ADON reviewed all GDRs with the IDT. The ADON distributed all pharmacy recommendations to either the Administrative Medical Assistant for processing or the DNP for review. One-on-one direction was given to the DNP about the internal process by the ADON. To prevent pharmacy recommendations responses from being delayed and to ensure they are part of the residents' medical records, the following has been completed and/or initiated: DON, ADON, and pharmacy consultant reviewed and updated the Medication Regimen Review Policy and changed the response timeframes for the attending physician/DNP to: 1) 45 days (from 60 days), after which the DON will bring them back to the attending physician/DNP. 2) 50 days (from 65 days), after which the DON will notify the Medical Director and/or the Administrator. The ADON completed one-on-one education with all charge nurses on the change of the internal process. On 5/5/2025, the DON verified that the processing of April's pharmacy recommendations had been completed and all had been sent to HIM to be scanned into the residents' medical records. To ensure the changes implemented are followed, the DON/ADON or designee will review: 1) The monthly Pharmacy Consultation Summary Reports weekly for progress. 2) If by Day 30, a pharmacy recommendation has still not been addressed, the DON will bring it back to the attending physician/DNP for review per the ICMCFS Medication Review Policy. The DON/ADON or designee will audit completed recommendations for: 1) Completion of pharmacy recommendations by the attending physician/DNP with signature and rationale. 2) That completed recommendations have been added to the residents' medical records. Audits will be conducted as follows: 10 audits for 1 month, 6 audits for 1 month, and 4 audits for 1 month. The DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by the DON/ADON to ensure compliance in accordance with the policy. The DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Duplicate Vitamin D Therapy Administered Due to Failure to Discontinue Prior Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a left femur fracture, mild cognitive impairment, urinary tract infection, and vitamin D deficiency received duplicate therapy of vitamin D. The resident was initially prescribed ergocalciferol (vitamin D2) 50,000 units weekly. Following a pharmacy recommendation, the physician accepted a change to cholecalciferol (vitamin D3) 50,000 units weekly, but the original vitamin D2 order was not discontinued. As a result, both vitamin D2 and D3 were administered concurrently throughout June, leading to an excessive total weekly dose of 100,000 units. The duplicate administration was confirmed through review of the medication administration record and pharmacy consultation reports. The DON and ADON acknowledged the error after reviewing the records and confirmed that the duplication was not detected due to a missed step in the double-checking process for physician orders. The facility's policy required thorough medication regimen reviews to prevent such issues, but the process failed to identify and resolve the duplicate therapy in this instance.
Plan Of Correction
The facility will develop a plan to ensure residents receive medications that are appropriate, necessary, and free from duplication. Review of the medical record indicates that Resident #90 has received the ordered dose of Vitamin D3 since July 1, 2024. The DON/designee reviewed the Drug Regime reviews for the month of April 2025. There was no duplicative therapy identified that the physician had not addressed. Physician Orders Policy given to the Nursing Administration Team and charge nurses in house for review, to verify and evaluate our current process. RCA completed by DON and ADON to identify how error occurred. Upon process review, we identified our transcription of orders would improve with redundancy built into the system. The Nursing Administrative Team revised the process to include a double note signature. 1:1 Education on the importance of double noting orders occurred for all charge nurses, neighborhood licensed staff, and nursing administrative team currently in the facility. All other nursing staff not in the building will be educated before or during their next shift. DON and ADON created a Physician Order Policy review with post-test for all licensed staff on Relias with focus on: double noting by licensed staff ensuring no duplicate orders and to identify the same medication under a different name. For those employees who are casual/student status, on vacation, or on LOA, Relias education will be completed before/during their next scheduled shift. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance. ADON updated Provider Visitation Log Sheets for DNP and Medical Director to include space to verify the order has been double noted by a licensed staff member. DON/ADON or designee will audit 2 Provider Visitation Log Sheets (that contain up to 22 orders) and 6 Omnicare pharmacy recommendation sheets weekly for one month to ensure order was processed per facility policy to ensure double noting was completed by second licensed staff. Then 1 provider visitation log sheet and 4 Omnicare pharmacy recommendation sheets weekly for one month, then 1 provider visitation log sheet and 2 Omnicare pharmacy recommendations weekly for one month. DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months; with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Administer and Maintain Oxygen and Nebulizer Equipment per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), anxiety, and dementia was observed receiving supplemental oxygen at a flow rate of 3 liters per minute (L/min) via nasal cannula, despite the active physician order specifying oxygen at 2 L/min as needed. Multiple observations confirmed the oxygen was being administered at the higher rate without any documented assessment or physician notification to justify the change. The resident's medical record did not contain documentation supporting the increased oxygen flow, and the most recent vital signs indicated an oxygen saturation of 97% on room air, with no evidence of a clinical need for the higher oxygen rate. Additionally, the oxygen tubing in use was found to be dated over a month prior to the observation, exceeding the facility's protocol for changing tubing every two weeks. Staff interviews confirmed the tubing was out of date and that the protocol for timely replacement was not followed. The resident was unaware of the oxygen concentration being administered and reported feeling more short of breath recently. Further observations revealed that the resident's nebulizer equipment, including the medication chamber and mouthpiece, was left resting directly on the nightstand without a protective barrier and was not stored in a sanitary manner as required by facility policy. Staff confirmed that the nebulizer equipment should have been cleaned, dried, and stored in a plastic bag after each use, but this was not done. Facility policies for both oxygen and nebulizer care were not followed, resulting in deficiencies in both the administration and maintenance of respiratory equipment.
Plan Of Correction
The facility will ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. For Resident #65, the DON and practitioner reviewed the resident's recent oximetry readings and assessed the resident's respiratory status, clarifying the oxygen liter flow ordered. The DON replaced, labeled, and dated the resident's oxygen tubing. The DON placed a barrier under the equipment and ensured a baggie was available to store tubing when not in use, per facility policy. The DNP reviewed the resident's record and completed an assessment with ongoing treatment for a diagnosis of COPD. No noted ill effects. On 4/17/2025, the DON identified those residents who are currently receiving oxygen and audited tubing for accuracy on labeling and to ensure correct storage units to coil and place tubing in a baggie when not in use. One of three was noted to have out-of-date oxygen tubing. The tubing was changed and labeled correctly. The DON also audited care plans for accuracy, and all three were up to date. The DON verified orders on all residents receiving oxygen to determine accuracy on the rate of flow the resident is receiving. The ADON obtained the current list of residents receiving nebulizer treatments. In each unit where these residents reside, the DON ensured nurses had proper cleaning supplies, an area to allow equipment to dry, and proper storage containers for nebulizer equipment. To prevent oxygen tubing from becoming outdated, ensure it is stored in a sanitary manner, and ensure oxygen is administered per physician order, the following has been completed and/or initiated: On 4/18/2025, the DON and ADON reviewed the following policies and deemed them appropriate with evidence-based practices: 1) Cleaning and Disinfecting Nebulizers Policy, 2) Oxygen Use and Set-up Policy, 3) Medication Administration Policy. On 5/1/2025, all nurses currently working in the facility received 1:1 education on the following: 1) Cleaning and Storage of oxygen tubing & nebulizer equipment, 2) 5 Rights of Medication Administration with a focus on checking the order to assure that oxygen is being administered at the ordered liter flow, 3) Hand Hygiene with a focus on during medication administration. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. The DON and ADON created a Relias education module and post-test for all licensed nursing staff, including a review of the Cleaning and Disinfecting Nebulizer Policy and Oxygen Use and Set-up Policy. The focus was on storing oxygen tubing, cleaning equipment after each use, changing oxygen tubing, and how/what to use to clean equipment. They also created a Relias education module and post-test for all CNAs, emphasizing storing tubing when not in use. 1:1 education was provided to AMA and NAA staff on the delivery of oxygen tubing and humidifier bottles, with an emphasis on: - Placing new tubing themselves and not delegating it out to another staff member. - Reapproaching the resident if unable to apply when they first attempt. - Reviewing the Oxygen Use and Set-Up Policy. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance: - DON/ADON or designee will complete audits of oxygen administered per physician order and labeling of oxygen tubing for accuracy, weekly for 2 months, and with random audits for 1 month. - Storing of equipment in a sanitary manner will be audited 2 times per week for one month, weekly for one month, and randomly for one month. The facility will schedule follow-up evaluations to ensure that these practices are maintained over the long term and that any trends are addressed promptly. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. The DON/ADON will be responsible for attaining and sustaining overall compliance with this plan of correction.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. During an interview and record review, it was found that the QAPI meeting sign-in sheets revealed inconsistent attendance by key members. On multiple occasions, essential members such as the Medical Director, Director of Nursing (DON), Infection Preventionist (IP), and Nursing Home Administrator (NHA) were absent. Specifically, the Medical Director was absent in three out of six meetings, the DON was absent in two meetings, and the IP and NHA were each absent in one meeting. This deficiency placed all 115 residents at risk for quality care concerns as the QAPI committee did not consistently meet with the required members to ensure proper oversight and quality improvement initiatives.
Failure to Prevent Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident (R266). R266, who was cognitively intact and admitted with diagnoses including a spinal fracture and ankylosing spondylitis, did not receive a dose of hydrocodone-acetaminophen that was signed out by RN H. The discrepancy was discovered when R266 requested the medication for back pain, and it was noted that RN H had signed out the medication but not documented its administration in the electronic Medication Administration Record (MAR). R266 confirmed he had not received the medication at the time it was signed out, leading to an investigation by the facility's Director of Nursing (DON) and other staff members. The investigation revealed that RN H had a history of careless documentation, including a previous incident where she signed out a controlled substance in the MAR but not in the narcotic sign-out log. During the investigation, RN H admitted to administering the medication but could not provide a consistent account of the event. RN H's behavior, including leaving the facility without permission and a history of increased PRN administration, raised further suspicion. When asked to submit to a drug test, RN H refused, leading to her immediate termination as per facility policy. The facility's policies on medication administration and drug testing were reviewed, confirming that refusal to submit to a drug test is treated as a positive result. The DON and Nursing Home Administrator (NHA) confirmed the termination of RN H due to her refusal to submit to the drug test. The facility had previously re-educated RN H after the first documentation incident but had not changed its policy at that time. The report highlights the failure to prevent the misappropriation of narcotic medication and the subsequent actions taken by the facility to address the issue.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. Resident #87, who was admitted with Alzheimer's Disease and was dependent on staff for all activities of daily living, was found on the floor with facial injuries and bleeding. Despite the severity of the injuries, which included facial fractures confirmed by a CT scan, the event was not reported to the state agency. The Director of Nursing admitted that the new cameras were not yet installed, making it impossible to validate the employees' statements, and the Nursing Home Administrator confirmed that the event was not reported because the investigation results ruled out abuse, although the facility was not able to immediately rule out abuse at the time of the incident. Resident #34, also admitted with Alzheimer's Disease and severe cognitive impairment, was found on the floor of her room and was sent to the hospital for x-rays and a CT scan, which revealed multiple fractures. Despite the resident's severe cognitive impairment and the unwitnessed nature of the injury, the event was not reported to the state agency. The Director of Nursing did not provide an explanation for the failure to report. The facility's policy on incident reporting clearly states that any incident requiring hospitalization should be reported to the Administrator and the State Health Department.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a thorough and complete investigation for an incident involving a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, anxiety disorder, major depressive disorder, type 2 diabetes, chronic pain, congestive heart failure, and primary hypertension. The resident, who requires substantial to maximum assistance to transfer, was found on the floor next to her wheelchair, complaining of left pelvic pain. The incident report revealed that the resident sustained a left inferior pelvic fracture, an anterior pelvic fracture, and a patella fracture. Despite the severity of the incident, the Director of Nursing acknowledged that the investigation into the incident was not completed, which is a violation of the facility's Incident Report Procedure that mandates investigations to be started within two working days and completed within fourteen days.
Failure to Assess and Monitor Pressure Injuries
Penalty
Summary
The facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for one resident. Resident #109 was admitted to the facility and initially had no pressure injuries. However, a pressure injury on the left gluteal area was identified on 3/7/24, but subsequent assessments and documentation were lacking. Additionally, a deep tissue injury on the left heel was identified on 3/12/24, but there was no further documentation or assessment of this injury in the resident's medical record. The Director of Nursing (DON) and other staff were unaware of the current status of these injuries, and there was no physician documentation on the pressure injuries. A skin assessment on 4/24/24 revealed a stage II pressure injury on the resident's sacrum, which had not been properly documented or treated according to the facility's policies. During interviews, the resident stated that nurses had not been assessing or treating the pressure injury on his bottom, and the DON confirmed that there was no additional documentation of the wounds in the resident's medical record. The facility's policies required weekly skin assessments and documentation for residents at risk for pressure injuries, but these were not completed for Resident #109. The lack of proper assessment, monitoring, and documentation of the pressure injuries led to a deficiency in the care provided to the resident. The facility's failure to follow its own policies and procedures for pressure injury assessment and treatment resulted in inadequate care for Resident #109. The DON and other staff members were not aware of the resident's pressure injuries, and there was no evidence of physician involvement in the assessment and treatment of these injuries. The facility's documentation practices were insufficient, and the required weekly skin assessments were not conducted, leading to a deficiency in the quality of care provided to the resident.
Failure to Report PBJ Information to CMS
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to CMS, resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024, which revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day on specific dates. An interview with an RN responsible for PBJ data submission confirmed that the facility missed the deadline for submitting the PBJ information to CMS. This failure had the potential to affect all 115 residents in the facility.
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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.
Surveyors found that multiple dependent residents did not receive consistent bathing, hair washing, shaving, or oral hygiene as required by their care plans and ADL needs. One resident with COPD, dementia, and a colostomy went at least 30 days without a documented shower or hair wash and was repeatedly observed with long chin hair despite stating she preferred it shaved. Another hospice resident’s showers and baths were provided only by hospice staff, with no evidence that facility CNAs delivered or documented any bathing during the review period, and hospice documentation was not incorporated into the facility record. A third resident with hemiplegia and major depression was observed with heavy facial hair and plaque on her teeth, reported concerns about shared razors, and had an unused personal electric shaver at bedside, while shower sheets showed no showers or bed baths in 30 days and only two documented refusals without evidence of re-approach or nurse notification.
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.
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 Provide and Document Basic ADL Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document basic activities of daily living (ADL) care, including bathing, hair washing, shaving, and oral hygiene, for multiple dependent residents. One resident with COPD, dementia, colon cancer with colostomy, anxiety, and depression required substantial to maximal assistance with showering, personal care, toileting, dressing, and transfers per the MDS and care plan. This resident reported that staff only sometimes shaved her facial hair and confirmed she preferred to have her chin shaved, yet surveyors repeatedly observed long chin hairs over several days. Review of the care plan showed she needed physical assistance with personal hygiene and that staff often needed to shave whiskers on her chin. Task sheets and shower documentation revealed no recorded bath or hair wash in the last 30 days, and two shower sheets within that period documented that she was not shaved on either shower day, with no explanation for missed showers or refusals. Further interviews and record reviews showed systemic documentation and scheduling issues contributing to the lack of care. A CNA stated the resident was scheduled for showers twice weekly and that refusals were to be documented on shower sheets and escalated to the nurse, but the facility could not produce adequate shower documentation for the prior 30 days. The DON later explained that CNAs did not know how to enter PRN showers and that when the resident was moved from one bed to another months earlier, her shower task days were not updated, leading CNAs to mark “NA” and follow an outdated schedule. The DON acknowledged that the resident had been moved in June of the prior year and that staff had continued to rely on the old schedule, and also acknowledged that no one had noticed the resident was not receiving showers as ordered. Another resident on hospice services, who was dependent on staff for all ADLs, also did not receive showers or baths from facility CNAs during the review period. Hospice coordination notes showed that a hospice CNA provided showers or baths on several specific dates, but there was no documentation that facility CNAs provided any showers or baths or documented refusals during the last 30 days. The DON stated that hospice admission information and visit notes were sent to the business office and ward clerk and were expected to be scanned into the electronic record or placed in a hospice binder, but record review revealed no hospice documentation in the electronic medical record or paper chart. The hospice binder was instead sitting in someone’s email account, and the DON stated she expected facility CNAs to provide care regardless of hospice involvement. A third resident with hemiplegia, muscle disorder, cervical disc disorder, fistula, difficulty walking, and major depression was dependent for all ADLs and was observed with visible plaque buildup on her teeth and heavy facial hair on her chin and upper lip. She reported that she had asked staff to shave her facial hair but was told the same razor was used on multiple residents, leading her to refuse that method and have her husband bring in an electric razor, which remained unused on her overbed table for at least a day. A CNA confirmed that the resident had not had her facial hair shaved until that point and that she was scheduled for a bed bath that day. The care plan directed staff to shave her face as needed and to encourage her to allow shaving, and there was no care plan entry stating she did not want her facial hair shaved. Shower sheets listed her for showers/bed baths twice weekly, but documentation showed no showers or bed baths in the last 30 days, with only two dates marked as refusals and no evidence of re-approach or nurse notification. The DON stated the expectation was twice-weekly showers or bed baths and acknowledged that refusals were only documented on two dates, with no corresponding progress notes showing re-approach or nurse follow-up, aside from a single progress note where the resident refused shaving with no documented follow-up.
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.
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