Iron River Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Iron River, Michigan.
- Location
- 330 Lincoln Avenue, Iron River, Michigan 49935
- CMS Provider Number
- 235601
- Inspections on file
- 26
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Iron River Care Center during CMS and state inspections, most recent first.
A resident with chronic pain syndrome, cancer, and intact cognition sustained a fall, striking the lower back on the bed frame and developing a large, very tender hematoma. Despite physician orders allowing ice then heat and later ordering warm compresses and scheduled oxycodone, staff delayed initiating non-pharmacological interventions, missed multiple ordered warm compress treatments, and failed to administer several scheduled oxycodone doses without documenting reasons. Pain assessments documented frequent, severe pain that interfered with sleep, rehab, and daily activities, and the resident reported staying in bed and becoming incontinent due to pain and fear of getting up. The DON and RN staff acknowledged delays in treatment and that increased pain was not communicated to the physician, while an x-ray later showed an L1 compression fracture associated with post-fall pain.
A resident with cancer, COPD, and anxiety, and intact cognition experienced a fall resulting in a large back hematoma/abrasion and later-confirmed L1 compression fracture with significant pain. Despite this change in condition and documented pain, the care plan was not revised to address post-fall pain, assessment of fracture-related pain, or non-pharmacological interventions such as warm compresses, contrary to facility policies requiring ongoing review and revision of the comprehensive care plan and incorporation of pain management interventions.
The facility failed to maintain comfortable temperatures, resulting in a non-homelike environment for four residents. Residents reported feeling cold, with temperatures recorded as low as 65 degrees. Maintenance staff acknowledged non-functioning heaters and drafts from door cracks. The Nursing Home Administrator was unaware of these issues, and staff wore jackets to stay warm. The facility's policy on maintaining a safe and homelike environment was not adhered to.
The facility inaccurately reported PBJ information to CMS, resulting in a deficiency for excessively low weekend staffing. The CMS PBJ Staffing Data Report for FY Quarter 2 of 2024 showed multiple instances of low staffing. Interviews revealed that the Business Office Manager/Human Resources submitted data without review, and the NHA was unaware of the staffing issue. The facility's policy requires verification of staffing data by the NHA, HR Director, and DON, which was not adhered to.
The facility's QAPI committee failed to meet the required membership and frequency of meetings, as the Medical Director or their designee was absent from two meetings. This non-compliance with the facility's policy could potentially decrease the quality of care for all 54 residents.
The facility failed to implement adequate infection control measures during a COVID-19 outbreak. Staff did not use PPE correctly, and there were no visual alerts or hand hygiene facilities at the alternative entrance used during construction. Five residents tested positive for COVID-19, and staff were observed not adhering to PPE protocols, such as wearing the same mask from a COVID-19 positive resident's room into the hallway. The facility's policy required visual alerts and instructions for PPE use and hand hygiene, which were not implemented, contributing to the deficiency.
The facility failed to properly manage medications brought in from home for nine residents, leading to the storage of opened, undated, and unlabeled medications in the medication room. Staff interviews confirmed that these medications should have been sent home or discarded, as per the facility's policies.
The facility failed to complete monthly medication regimen reviews for four residents, resulting in missing consultation reports and unaccounted pharmacist recommendations. The DON confirmed the absence of these reports and could not verify follow-up actions. Additionally, one resident's medication reviews were missing for several months, despite being on antipsychotic and antidepressant medications.
The facility did not adequately address or respond to concerns raised by residents during Resident Council meetings. Residents reported that their complaints were repeatedly discussed but not resolved, and the Activity Director admitted to not effectively reviewing or documenting these concerns. Meeting minutes showed inconsistencies and a lack of follow-up on issues like cold food, indicating a failure to act upon and communicate resolutions as required by policy.
A facility failed to report an allegation of potential sexual abuse between two residents, one with moderate and the other with severe cognitive impairment. Despite a grievance being filed by a resident, the incident was not reported to the State Survey Agency as required. Interviews revealed that the Social Services Designee informed the DON and NHA, but no investigation or report was made. The facility's policies mandate reporting such allegations, which was not adhered to.
The facility failed to investigate an allegation of potential sexual abuse between two residents. A resident with moderate cognitive impairment reported that another resident with severe cognitive impairment attempted to get into their bed repeatedly. Despite the facility's policies requiring immediate investigation of such allegations, no investigation or documentation was found.
The facility did not provide written transfer notifications to two residents and their representatives when they were transferred to the hospital. The Nursing Home Administrator admitted the oversight, and the Corporate Director of Clinical Services confirmed that such notifications are required by the facility's policy.
The facility did not provide written notification of the bed hold policy to two residents upon their transfer to a hospital. The Nursing Home Administrator confirmed that the required notice, which should specify the duration of the bed hold and information about the resident's return, was not given as per the facility's policy.
A facility failed to develop a trauma-informed care plan for a resident with dementia and behavioral disturbances, despite being informed of the resident's history of severe physical abuse. The resident's care plan lacked focus areas, goals, or interventions related to trauma, and no trauma assessment was conducted, contrary to the facility's policy.
A resident with dementia and muscle weakness suffered a skin tear during a transfer due to improper use of a sit-to-stand lift instead of the care-planned total mechanical lift. The CNA involved was in a hurry and did not follow the care plan, leading to the resident's arm hitting a door jamb. The facility's policy on safe transfers was not adhered to, and staff were unaware of the correct transfer method as per the resident's care plan.
A facility failed to conduct a trauma assessment for a resident with dementia and a history of physical abuse, resulting in inaccurate information for mental health professionals. Despite the resident's spouse informing the facility of the abuse history, no trauma assessment was completed, and the Social Services Director did not convey this critical information to the mental health provider. This led to potential uninformed care, contrary to the facility's trauma-informed care policy.
The facility failed to serve meals at satisfactory temperatures, affecting several residents. Observations revealed that food temperatures were not recorded, and items were served below the required holding temperature. A resident reported consistently receiving cold meals, and past complaints were noted. The facility's food safety policy was not followed, leading to this deficiency.
A facility failed to maintain current legal guardianship for a resident deemed incompetent, allowing a family member to make unauthorized decisions. The guardianship had expired, and the facility lacked updated documentation, with the family member refusing to provide it. The facility's policy did not ensure guardianship validity, leading to this deficiency.
A resident was readmitted with an indwelling urinary catheter but lacked necessary physician orders and a care plan. The facility did not have orders for catheter maintenance or a care plan to guide staff, as confirmed by the DON. This oversight was against the facility's policy on catheter use and removal.
Failure to Provide Ordered Pain Management After Fall With Back Hematoma and Compression Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered pain treatment and pain medication for a resident following a fall, resulting in prolonged, inadequately relieved pain and a decline in urinary continence. The resident, who had chronic pain syndrome, cancer, COPD, and anxiety disorder, was cognitively intact and had a history of frequent pain that interfered with sleep, rehabilitation, and daily activities. On the date of the fall, the resident reported that her legs gave out and her back struck the bed frame, causing unbearable pain and a large, tender hematoma on the lower back. The incident report documented a large hematoma/abrasion with missing skin and bleeding, and the resident rated her pain as 6/10 at that time. A physician progress note from that day documented a very tender large hematoma and contusion to the lower back, with instructions that ice could be used for two days followed by heat, and that oxycodone might need to be increased if pain was uncontrolled. In the days following the fall, the resident reported excruciating pain to a family member and stated that her pain medication did not relieve the pain. She reported staying in bed for days, being afraid to get up due to pain, and becoming incontinent in bed because she did not get up to use the bathroom. A CNA confirmed that after the fall the resident complained of pain, was concerned about the appearance of the hematoma, did not get out of bed due to pain, and was incontinent for a couple of days. Nursing pain assessments documented that the resident had frequent pain over multiple five-day periods, with pain frequently making it hard to sleep, limiting participation in rehabilitation, and limiting day-to-day activities. Pain intensity was documented as very severe/horrible shortly after the fall and later as 5, with notes linking the pain to the hematoma from the fall. Despite these findings, there were multiple failures to implement and consistently provide ordered pain-related interventions. The DON and RN staff acknowledged that non-pharmacological interventions such as cold or hot/warm compresses, which the physician and DON described as standard of care for a hematoma, were not initiated until about a week after the fall, and skin evaluations on 1/7 and 1/14 documented the back bruise/hematoma with "no interventions." When warm compresses were finally ordered on 1/14 to be applied three times daily, the MAR showed multiple missed administrations with no documented rationale. The resident’s scheduled oxycodone regimen for chronic pain and later for trochanter pain was also not administered at several scheduled times on multiple days, again without documentation of why doses were omitted. The DON acknowledged a delay in treatment, uncertainty about whether the physician was notified of increased pain, and that the resident’s increased pain was not communicated to the physician, while the physician stated that staff did not inform him of increased pain and that he was unaware of it until a follow-up visit. An x-ray ordered on 1/14 and completed on 1/16 revealed a compression fracture of the L1 vertebra associated with post-fall pain. The facility’s pain management policy required recognition, evaluation, and management of pain, use of non-pharmacological interventions such as cold compresses, and practitioner notification when pain was not controlled, but the documented actions and omissions showed that these standards were not followed for this resident. The cumulative effect of these failures—delayed initiation of non-pharmacological interventions, inconsistent provision of ordered warm compresses, missed doses of scheduled oxycodone without explanation, and lack of timely communication to the physician about increased pain—resulted in the resident experiencing prolonged pain that was not adequately relieved by medications and a decline in urinary continence, as the resident remained in bed and was incontinent due to fear of worsening pain when getting up.
Failure to Revise Care Plan After Fall-Related Compression Fracture and Pain
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan following a significant change in condition related to pain. The resident was admitted with active diagnoses including cancer, COPD, and an anxiety disorder, and had intact cognition as evidenced by a BIMS score of 14/15. An incident report documented that at 3:00 a.m. the resident called out to staff after a fall, and staff found the resident on her bed with a large hematoma and abrasion on the middle/lower back, measuring approximately one inch in height and three inches in length, with areas of missing skin and slight bleeding. The resident reported pain at a level of 6 on a 0–10 scale. An x‑ray report later documented a compression fracture of the upper end plate of the L1 vertebra associated with trauma and severe localized pain. Despite this new injury and ongoing pain, review of the resident’s care plan showed it was not updated to address pain post‑incident or to include interventions such as warm compresses. The facility’s Comprehensive Care Plans policy required that the comprehensive care plan be reviewed and revised by the interdisciplinary team as needed with any changes in the resident’s plan of care, and the Pain Management policy required that pain management interventions, including non‑pharmacological measures such as cold compresses, be incorporated into the comprehensive care plan and revised if pain was not adequately controlled. The DON confirmed that no interventions were added to the care plan regarding non‑pharmacological pain interventions, assessment of pain from the fracture, or warm compresses, and acknowledged that the care plan should have been updated.
Failure to Maintain Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable temperatures, resulting in a non-homelike environment for four residents. Resident #1, with intact cognition, reported feeling cold for several days, noting that staff were also wearing extra clothing to stay warm. Resident #2, with moderate cognitive impairment, mentioned a persistent cold draft from the window, which was temporarily blocked with a towel, but maintenance had not resolved the issue. Resident #3, also with intact cognition, kept a log of room temperatures, which were recorded as low as 65 degrees, and reported wearing a winter coat indoors due to the cold. Resident #4, with intact cognition, described the coldest periods as occurring during the night and early morning, requiring extra blankets and a hat to stay warm. Observations and interviews with staff corroborated the residents' complaints. Maintenance staff acknowledged the low temperatures and non-functioning heaters at the end of hallways. Temperature readings taken by staff showed temperatures ranging from 65 to 68 degrees in various parts of the facility, below the facility's policy of maintaining temperatures between 71 and 81 degrees. Additionally, cracks at the bottom of doors leading to the outside were observed, contributing to drafts and cold air entering the facility. The Nursing Home Administrator was unaware of the door cracks, and staff reported wearing jackets during shifts due to the cold. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the low temperatures and drafts affecting resident comfort. The deficiency was identified through a combination of resident interviews, staff statements, and direct observations by the surveyor.
Inaccurate PBJ Reporting Leads to Low Weekend Staffing Deficiency
Penalty
Summary
The facility failed to accurately report Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in a deficiency related to excessively low weekend staffing. The CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024 indicated that the facility triggered for excessively low weekend staffing on multiple dates throughout January, February, and March 2024. During interviews, the Business Office Manager/Human Resources stated that they submit the PBJ information but do not review the data, while the Nursing Home Administrator expressed confusion about the low weekend staffing trigger. The facility's policy requires the Nursing Home Administrator, Human Resource Director, and Director of Nursing to verify the accuracy of staffing data submitted to CMS, but this verification process was not followed, leading to the deficiency.
QAPI Committee Membership and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met the required membership and frequency of meetings, which could potentially decrease the quality of care for all 54 residents. The QAPI committee meetings were held on three occasions: August 14, 2023, January 30, 2024, and May 1, 2024. However, the Medical Director or their designee was not present at the meetings on August 14, 2023, and January 30, 2024. According to the facility's policy, the QAPI committee must include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members, including the Administrator, Owner, a Board Member, or another individual in a leadership role, and the Infection Preventionist. The absence of the Medical Director or their designee at these meetings indicates non-compliance with the facility's policy requirements for the QAPI committee's composition and meeting frequency.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure the correct use of personal protective equipment (PPE) and did not post visual alerts at the entry for staff and visitors regarding hand hygiene and source control during a COVID-19 outbreak. Observations revealed that the main entrance was closed for construction, and an alternative entrance was being used without proper signage or hand hygiene facilities. Staff were observed entering and exiting the facility without wearing masks or performing hand hygiene, and there was no process in place to inform individuals entering the facility of the recommended actions to prevent COVID-19 transmission. The Infection Preventionist (IP) confirmed that five residents tested positive for COVID-19, all residing on the 200 unit. Despite this, staff were observed not adhering to proper PPE protocols, such as wearing the same mask from a COVID-19 positive resident's room into the hallway and other rooms. Additionally, residents who tested positive were seen in common areas without proper isolation, and staff were observed wearing gloves from one resident's care to another without changing them or performing hand hygiene. The facility's policy required visual alerts and instructions for PPE use and hand hygiene, which were not implemented at the alternative entrance. The IP admitted that signage was not posted as required, and staff were not following CDC guidelines for infection prevention and control. The lack of proper signage, PPE use, and hand hygiene practices contributed to the deficiency in preventing the transmission of COVID-19 within the facility.
Improper Medication Storage and Handling
Penalty
Summary
The facility failed to ensure the proper return or destruction of medications brought in from home for nine residents out of a total population of 54. During an observation, four pink bins containing various medications were found in the medication storage room's upper wall cabinets. These bins included opened, undated, and unlabeled medications such as topical creams, stoma powder, antifungal medication, and prescription bottles for specific residents. Additionally, a seven-day pill container with unidentified pills and several unlabeled medication bottles were found without any resident identification. Interviews with staff revealed that these medications should not have been stored in the facility. Registered Nurse K acknowledged that the medications should have been sent home with the residents or discarded. The Nursing Home Administrator and Corporate Director of Clinical Services also recognized that the open, unlabeled, and un-inventoried medications should not have been retained in the facility. The facility's Medication Storage policy and Destruction of Unused Drugs policy require routine inspection and destruction of unused medications, which was not adhered to in this instance.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure the completion of monthly medication regimen reviews for four residents, leading to the potential for administration of unnecessary or inappropriate medications. For three residents, the electronic medical records indicated that medication regimen reviews were completed, and recommendations were made by the pharmacist. However, there were no consultation reports available in the records to show what the recommendations were, when they were received, or how and when the facility followed up on them. The Director of Nursing (DON) confirmed the absence of these reports and could not account for the receipt and follow-up of the recommendations. For another resident, the facility did not have records of monthly medication regimen reviews for several months, despite the resident being prescribed antipsychotic and antidepressant medications. The DON acknowledged the absence of these reviews in the electronic medical record for the specified months. The facility's policy requires that the drug regimen of each resident be reviewed at least once a month by a licensed pharmacist, and that written communications from the pharmacist become a permanent part of the resident's medical record.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and respond to concerns and grievances raised by residents during Resident Council meetings. During a confidential group meeting, several residents expressed that their complaints were repeatedly discussed in council meetings but were not addressed or resolved. The Activity Director acknowledged not effectively reviewing or documenting these concerns, which is contrary to the facility's policy that requires the liaison to respond to written requests from group meetings and communicate decisions back to the council. Additionally, a review of the Resident Council meeting minutes revealed inconsistencies and a lack of follow-up on previously discussed issues. For instance, concerns about cold food raised in the June meeting were not addressed in subsequent meetings, and there was no meeting held in July. This lack of documentation and follow-up indicates a failure to act upon and communicate resolutions to the residents' concerns, as required by the facility's policy.
Failure to Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to report an allegation of potential sexual abuse between two residents, resulting in a deficiency. Resident #3, who has moderate cognitive impairment, reported that Resident #205, who has severe cognitive impairment, attempted to get into their bed multiple times, including an incident at 1 a.m. Despite Resident #3's grievance, which was documented on a resident grievance form, the event was not reported to the State Survey Agency as required by the facility's policy. Interviews with facility staff revealed that the Social Services Designee reported the incident to the Director of Nursing (DON) and the Nursing Home Administrator (NHA). However, the DON did not personally report the event and was unsure if the NHA had done so. The NHA confirmed that there was no investigation into the grievance and that it was not reported. Additionally, there was no documentation of the event in the electronic medical records of either resident. The facility's policies on grievances and abuse reporting clearly state the requirement to report such allegations to the state agency, which was not followed in this case.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential sexual abuse between two residents, identified as Resident #3 and Resident #205. Resident #3, who has moderate cognitive impairment, reported through a grievance form that Resident #205, who has severe cognitive impairment, attempted to get into their bed repeatedly, including an incident at 1 o'clock in the morning. Despite these allegations, the Nursing Home Administrator confirmed that no investigation into the grievance was conducted, and there was no documentation of the event in the residents' Electronic Medical Records. The facility's policies on Resident and Family Grievances and Abuse, Neglect, and Exploitation require immediate investigation of any allegations involving abuse. The policies designate the Nursing Home Administrator and/or Social Service Designee as responsible for leading investigations and reporting allegations of abuse. However, in this case, the facility did not adhere to its policies, as there was no investigation or documentation of the alleged incidents involving Residents #3 and #205.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer notifications to two residents and their representatives when the residents were transferred to the hospital. Resident #7 was transferred on July 19, 2024, and Resident #15 on June 27, 2024, without any written notification documented in their medical records. On August 28, 2024, the Nursing Home Administrator acknowledged that the facility did not issue the required written notifications for these transfers. The Corporate Director of Clinical Services confirmed that written notifications were necessary according to the facility's policy, which mandates that transfer or discharge notices be provided to the resident, their representative, and the LTC ombudsman as soon as practicable when an immediate transfer is required due to urgent medical needs.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents, identified as R7 and R15, upon their transfer to a hospital. Resident #7 was transferred on July 19, 2024, and Resident #15 on June 27, 2024. In both cases, the medical records lacked documentation indicating that the bed hold policy was communicated to the residents or their representatives. This was confirmed by the Nursing Home Administrator on August 28, 2024, who acknowledged that the facility did not provide the necessary written notice at the time of transfer. The facility's policy, dated May 28, 2024, requires that such notification be given to residents or their representatives, specifying the duration of the bed hold and information about the resident's return to the next available bed.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered, and trauma-informed care plan for a resident with a primary diagnosis of dementia with behavioral disturbance. The resident, who was admitted to the facility with severe cognitive impairment, exhibited behavioral symptoms such as physical and verbal aggression towards others, as well as self-directed behaviors. Despite the resident's spouse informing the facility of a history of severe physical abuse, which was believed to contribute to the resident's behavioral symptoms, no trauma assessment was conducted upon admission or thereafter. The resident's comprehensive care plan lacked focus areas, goals, or interventions related to the history of trauma and potential triggers. The Social Services Director acknowledged awareness of the resident's history of abuse and confirmed that no trauma assessment or appropriate care plan was developed. The facility's policy on Trauma Informed Care outlines the need for a trauma-informed approach, including the use of screening and assessment tools and collaboration with the resident's support network to develop individualized care plan interventions. However, these procedures were not followed, resulting in a deficiency in providing trauma-informed care for the resident.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe resident handling during transfers, resulting in a skin tear for a resident with dementia, difficulty walking, and muscle weakness. The resident required substantial/maximal assistance for transfers, as indicated in her Minimum Data Set (MDS) assessment. Despite this, the resident was transferred using a sit-to-stand lift instead of the care-planned total mechanical lift, leading to a skin tear when her arm hit the door jamb during a hurried transfer to the bathroom by a CNA. The incident report revealed that the CNA was in a hurry and did not follow the care plan, which required a total mechanical lift due to the resident's previous fall from a sit-to-stand lift. The CNA admitted to transferring the resident alone and acknowledged that the resident became limp during the transfer, necessitating assistance from two additional CNAs to complete the transfer. The resident's care plan had conflicting interventions, with the use of a total mechanical lift not canceled until after the incidents. Interviews with facility staff, including the DON and the CNA involved, highlighted a lack of awareness and adherence to the resident's care plan. The DON was unaware of the care plan's requirement for a total mechanical lift, and the CNA involved in the previous fall incident also did not ensure the sling was properly secured. The facility's policy on safe resident handling and transfers was not followed, as the resident's individual plan of care was not adhered to, leading to the deficiency.
Failure to Conduct Trauma Assessment for Resident with Abuse History
Penalty
Summary
The facility failed to complete trauma assessments and identify behavioral triggers for a resident with a history of physical abuse, leading to inaccurate information being available to mental health professionals. The resident, who was admitted with a primary diagnosis of dementia with behavioral disturbance, exhibited severe cognitive impairment and behavioral symptoms such as physical and verbal aggression. Despite the resident's spouse informing the facility of a history of severe physical abuse, no trauma assessment was conducted upon admission or thereafter. The Social Services Director, who was aware of the resident's history, did not conduct a trauma assessment due to being new to the role. Consequently, the resident's electronic medical record lacked documentation of the abuse history, which was not communicated to the mental health provider during a recent assessment. This omission resulted in the mental health provider's history of present illness note inaccurately reflecting the resident's abuse history, potentially leading to uninformed and misguided care. The facility's policy on trauma-informed care emphasizes the importance of identifying trauma history and collaborating with relevant parties to develop individualized care plans, which was not adhered to in this case.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at satisfactory temperatures, affecting four residents, including one identified as R42 and three others from a confidential group interview. During an observation on 8/26/24, it was noted that the cook, Staff L, did not record food temperatures for the lunch meal being served. Upon checking, the temperatures of the food items were found to be below the required holding temperature of 135 degrees Fahrenheit, with items such as potatoes and carrots measuring 129 and 118 degrees, respectively. Staff M, the Dietary Manager, confirmed that there were no recorded food temperatures for several previous dinners, and acknowledged past complaints about cold food. Resident 42 expressed dissatisfaction with the temperature of the meals, stating that the food was usually cold by the time it reached him. The resident's medical records indicated intact cognition with a Brief Interview for Mental Status evaluation score of 15 out of 15. Additionally, the Resident Council meeting minutes from 6/12/24 included a resident's comment that, although the food tasted good and had improved, it was still cold. During a confidential group interview, multiple residents reiterated complaints about receiving cold food. The facility's policy on food safety, which requires monitoring and maintaining proper food temperatures, was not adhered to, contributing to the deficiency.
Expired Guardianship for Incompetent Resident
Penalty
Summary
The facility failed to ensure that the legal guardianship for a resident, who was declared incompetent by a court of law, was renewed and active. The resident, identified as Resident #41, was deemed unable to make informed decisions regarding living arrangements, supportive services, financial affairs, and medical treatment. A family member, FM J, was appointed as the temporary guardian with authority over these decisions. However, the guardianship was temporary and had expired, yet FM J continued to make decisions on behalf of the resident without current legal authority. During the survey, the Nursing Home Administrator directed inquiries about guardianship to the Registered Nurse and the Director of Nursing. Upon review, it was found that the facility did not have updated guardianship paperwork for the resident. The Director of Nursing confirmed the expiration of the guardianship and reported that FM J refused to provide updated documentation, suggesting the facility contact the courthouse instead. The facility's policy on resident rights and advance directives did not include a process for ensuring that legal guardianship was current and valid, contributing to the deficiency.
Lack of Physician Orders and Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had the necessary physician orders and a care plan in place. The resident was readmitted to the facility with a catheter but lacked physician orders for the catheter itself, the frequency of catheter changes, and the changing of the urinary drainage bag. Additionally, there was no care plan developed to guide staff on the maintenance and care of the catheter. The Director of Nursing confirmed that physician orders and a care plan are required for residents with catheters. Upon review, it was found that these were not entered into the resident's medical record upon readmission. The facility's policy on indwelling catheter use and removal emphasizes the need for justification or removal of catheters according to regulations and standards, which was not adhered to in this case.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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