Maple Valley Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Maple Valley, Michigan.
- Location
- 1086 W. Burdickville Road, Maple Valley, Michigan 49664
- CMS Provider Number
- 235588
- Inspections on file
- 20
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maple Valley Nursing Home during CMS and state inspections, most recent first.
A newly installed boiler heating unit was found to lack manufacturer information and proof of state inspection. The facility could not provide documentation that required corrections identified by a state boiler inspector had been completed, and a final inspection had not been requested.
Surveyors observed multiple failures in food storage, hand hygiene, glove use, and beard net compliance by dietary staff, including unlabeled and undated food, improper hand washing, and repeated use of contaminated gloves during food preparation and service. The dietary manager confirmed staff did not consistently follow required procedures, and facility policies were not adhered to, potentially impacting all residents.
The facility did not establish or implement an effective infection prevention and control program, failed to update related policies, and did not conduct required infection surveillance or investigations. Staff did not use enhanced barrier precautions during high-contact care for a resident with multiple wounds, and an LPN failed to perform hand hygiene during medication administration for several residents, contrary to facility policy.
Three residents experienced delayed meal service when staff received lunch trays before all residents were served, resulting in frustration and hunger for those waiting. One resident, dependent on staff for all ADLs and unable to speak, waited over two hours for a meal, while two others reported being hungry and not having received their lunch. Staff interviews confirmed the delay, and facility policy requires residents to be served before staff.
A resident with COPD reported shortness of breath and requested her inhaler. An LPN administered albuterol without performing or documenting a respiratory assessment or O2 sat before or after administration. The DON confirmed that such assessments are expected, but facility policy did not specify this requirement.
The facility did not ensure that DNR orders for three residents with serious medical conditions were promptly accessible to staff in emergencies. DNR status was not entered in the EMR's code status bar or as a physician's order, and staff had difficulty locating the information, sometimes relying on a paper binder in the DON's office. This resulted in delays in identifying residents' code status during critical situations.
A resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive required monthly CBC monitoring while on clozapine, due to staff failing to obtain blood samples and incomplete task tracking. The DON confirmed that missed lab draws were not reported, resulting in a lapse in monitoring for two months.
A resident with diabetes and other conditions did not have recommended lab draws for A1C and magnesium completed, despite pharmacy and physician agreement. The required A1C lab was missed due to issues with order entry and communication among staff, and there was no documentation that pharmacy recommendations for updated labs were addressed, contrary to facility policy.
A nurse, distracted by multiple residents at the med cart, administered another resident's medications—including Depakote, Seroquel, and vitamin D3—to a resident with a history of hypertension, diabetes, stroke, and depression. This resulted in the resident experiencing lethargy and confusion, in violation of the facility's medication administration policy.
The facility failed to provide up-to-date education and documentation regarding pneumococcal vaccines for two residents, using outdated consent forms and not supplying the most current CDC Vaccine Information Statements. Additionally, a resident did not receive a pneumococcal vaccination despite guardian consent, with no clinical reason documented for withholding it. Facility policies and standing orders were also not updated to reflect current CDC recommendations for PCV15, PCV20, or PCV21.
A facility failed to conduct regular skin assessments for a resident with a history of skin breakdown, leading to unaddressed redness and irritation. Despite the facility's policy requiring weekly assessments, only one assessment was documented shortly after admission. Interviews with staff confirmed the lack of adherence to the policy, resulting in a deficiency in quality of care.
A resident with moderate cognitive impairment sustained a second-degree burn after being served hot soup and left unattended in a reclined position. The soup, held at 173°F, spilled on her upper torso when she attempted to feed herself. Staff interviews revealed improper positioning for eating in bed, and the facility's policy required burn potential assessments, which were not documented.
A facility experienced a deficiency when two former CNAs removed a resident with severely impaired cognition and on hospice care from the premises without authorization or necessary medications. The resident was taken to an unknown location for approximately 16 hours, lacking proper consent or supervision. The incident highlighted lapses in following protocols for resident leave of absence, including the absence of a physician's order and failure in staff communication and oversight.
A resident with moderate cognitive impairment and a history of falls sustained injuries after falling in a common bathroom, highlighting the absence of a completed Fall Risk Assessment and insufficient supervision. Another resident with vascular dementia and a history of wandering eloped multiple times, indicating a lack of effective interventions to prevent elopement and ensure safety.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards by not disposing of expired food in kitchen refrigerators. Six expired containers of juice were found in the reach-in refrigerator, with no received dates labeled on top. The Kitchen Manager acknowledged missing these items during a recent check.
The facility failed to effectively administer its policies and procedures, impacting the well-being of all 22 residents. Key issues included the absence of the NHA during a critical IJ delivery, failure to report and investigate a resident's unauthorized LOA, inadequate staff support and training, and non-compliance with infection control and smoking policies. These deficiencies led to undetected abuse, potential psychosocial harm, and safety risks.
The facility failed to ensure the designated Infection Preventionist completed the required specialized training. The MDS Coordinator, who served as the IP from January 2023 through March 2024, did not finish the necessary training, citing time constraints. The DON and NHA confirmed this deficiency, which was documented in CMS Form #20054.
The facility failed to ensure monthly drug regimen reviews were completed and that recommendations were reviewed by a physician for multiple residents. Missing documentation and follow-up indicate a systemic issue in handling MRRs and pharmacist recommendations.
The facility failed to ensure resident rights training for three of seven employees reviewed. The Nursing Home Administrator and a Registered Nurse had not completed the required training within the 12-month period, and an Agency CNA had not completed any training. The Director of Nursing confirmed the lapses in training during an interview.
The facility failed to ensure that two residents were free from physical restraints imposed for convenience. Both residents had tab alarms used without proper documentation, consent, or physician orders, as confirmed by the Director of Nursing.
A resident with severe cognitive impairment and under hospice care was taken out of the facility overnight by two former CNAs without the guardian's permission. The facility failed to notify the guardian and the appropriate authorities in a timely manner, leading to significant distress and concern for the resident's safety. The incident was not reported to the State Agency as required by the facility's policies.
A resident with severe cognitive impairment and multiple medical conditions was taken out of the facility overnight by two former CNAs without the guardian's permission. The facility failed to follow proper procedures for obtaining permission, notifying appropriate parties, and investigating the incident, leading to significant distress and involvement of local law enforcement.
The facility failed to provide written transfer notifications to two residents when they were transferred to the hospital. The Director of Nursing in Training confirmed that the facility did not follow its policy, citing the small size of the building and the practice of notifying residents and their representatives individually.
The facility failed to provide written information to residents or their representatives regarding bed hold policies during hospital transfers, resulting in unawareness of potential expenses. The Director of Nursing in training admitted the facility did not follow its policy and lacked a specific bed hold form.
The facility failed to submit a quarterly MDS assessment for a resident with multiple diagnoses, including dementia and kidney disease. The last assessment was overdue by more than two months, and the LPN responsible discovered that the resident was not scheduled on the EMR scheduler, possibly due to a deletion error.
The facility failed to review, revise, and send PAS/ARR documents for a resident with mental illness and dementia to the local state agency. The required DCH-3878 form was missing from the resident's EMR, and the Social Services Director, recently employed, could not explain the oversight.
A facility failed to develop a resident-centered care plan for a resident with multiple medical diagnoses, including severe allergies and smoking habits. The care plan lacked focus areas, goals, or interventions related to the resident's smoking and severe allergy to bee stings, despite the resident's history of anaphylactic reactions and unsupervised smoking outdoors.
The facility failed to assess, reassess, obtain consent, and develop care plan interventions for a resident using mobility bars. The resident was unaware of signing a consent, and the use of mobility bars was not documented in the MDS assessments or care plan.
The facility failed to follow a physician's order for a resident requiring [NAME] hose and did not obtain emergency medication for another resident with a severe bee sting allergy, resulting in inadequate care and supervision.
A resident with a history of PTSD was not provided with trauma-informed care, leading to distress from another resident's yelling. The social worker was unaware of the resident's PTSD history and had not conducted an assessment to identify triggers, resulting in inappropriate care plan interventions.
The facility failed to ensure appropriate assessment, measurements, and consent for bedrails for a resident. Observations and record reviews revealed that the resident's bed had mobility bars without documented consent, assessment, or gap measurements. The DON confirmed the requirement for these documents but could not provide them.
The facility failed to coordinate behavioral health services for a resident with severe cognitive impairment and multiple behavioral health diagnoses. Despite recommendations for follow-up consultations, the resident exhibited ongoing violent behaviors and suicidal ideation without appropriate mental health intervention. The lack of a trained social worker and structured procedures contributed to the oversight.
A resident with schizophrenia and chronic kidney disease was mistakenly given Miralax by a nursing assistant in training. The DON had prepared the Miralax and labeled it, but the nursing assistant gave it to the resident without realizing it contained medication. The facility's policy requires prompt physician notification and close monitoring, but these steps were not documented in the resident's medical record.
A resident with multiple diagnoses was on a leave of absence and returned to the facility at 9:48 AM. However, the MAR inaccurately indicated that medications were administered at 8:00 AM. The DON confirmed the error, and there was no documentation of a medication error or notification to the attending physician as required by facility policy.
The facility failed to implement enhanced barrier precautions (EBP) for a resident with open wounds. Despite the resident's ongoing wound treatment, there was no transmission-based precaution (TBP) signage, and a nurse was observed performing wound care without proper PPE. The infection preventionist admitted that staff had not been fully educated on EBP procedures, leading to the deficiency.
The facility failed to offer an influenza vaccine to a resident with moderate cognitive impairment, despite CDC recommendations and the vaccine being due. The last documented administration was over three years ago, and no recent offering was found in the resident's records.
The facility failed to maintain an effective abuse and dementia management training program for three staff members. The NHA and an RN had not completed the required abuse, neglect, and exploitation training within the required 12-month period, and an Agency CNA had not completed the facility's abuse training program. Additionally, the NHA and the same CNA had not completed the required dementia training. The DON confirmed the training lapses during an interview.
The facility failed to ensure infection control training for four of seven employees reviewed. The NHA had a future date listed for training, a CNA and the DON did not complete the required Infection Control Annual Inservice, and an agency CNA also did not complete the required training.
A resident with intact cognition and multiple diagnoses was involved in inappropriate social media exchanges with a housekeeping staff member, leading to potential mental and sexual exploitation. The resident's guardian discovered the messages and reported them to the facility. Attempts to contact the staff member were initially unsuccessful, but their identity was confirmed through social media. Facility staff confirmed that such relationships are not allowed.
Lack of Documentation and Final Inspection for Newly Installed Boiler
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with regulatory requirements, specifically section 9.2. During an observation, it was found that a newly installed boiler heating unit lacked manufacturer information and proof of a State of Michigan boiler inspection. The office manager was unable to confirm whether the necessary corrections identified by the state boiler inspector during a previous visit had been completed, and only had limited information about the inspector. Further confirmation from the State of Michigan boiler inspector indicated that the required corrections on the new boiler installation had not yet been completed, and a final inspection had not been requested.
Plan Of Correction
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The boiler was inspected and did not pass. Contractor has made the required repairs and is calling to schedule another inspection as soon as possible. Once the state boiler inspection has been completed, the local building department will perform their inspection. I personally spoke with the state boiler inspector on Friday, as the contractor is not fulfilling his responsibilities of completing this project and scheduling the inspection. The inspector said he would be able to come on Monday, June 30 or July 1, but I have not heard back with a confirmed date or time. I am unable to force the contractor or inspector to get this taken care of in a timely manner, so I do not have firm dates that it will be inspected or approved. Address how the facility will identify other residents having a potential to be affected by the same deficient practice: The residents are not affected by this deficient practice. The boiler is not in use as it is not heating season and operates as designed when needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: This contractor will not be used again in the future. Maintenance Director will ensure any future contractors will complete permits and inspections prior to being paid in the future. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Maintenance director will monitor weekly and maintain communication with contractor to ensure the inspections are completed. Will be discussed at quarterly QAPI meetings.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of improper food storage and handling practices. Surveyors found several food items, such as English muffin breakfast sandwiches and a bag of chicken breast, stored in the refrigerator and cooler without proper labeling or dating. Despite posted instructions to date foods removed from the freezer, staff were unaware of or did not follow these procedures. Additionally, staff could not account for certain food items found in storage, indicating a lack of oversight and adherence to food storage policies. Numerous instances of improper hand hygiene and glove use were observed among kitchen staff and aides. Staff were seen washing their hands for less than the required time, turning off faucets with bare hands, and failing to perform hand hygiene after tasks that could contaminate their hands, such as handling soiled items or touching their face. Staff also repeatedly used the same gloves for multiple tasks, including serving food, preparing meals, and delivering trays, without changing gloves or washing hands between tasks. In some cases, staff placed used gloves on clean prep surfaces, further increasing the risk of cross-contamination. Additional deficiencies included staff not wearing required beard nets while preparing food, despite having visible facial hair, and a lack of posted hand washing instructions at the kitchen sink. The facility's own policies required proper hand washing, glove use, and beard net use, but these were not consistently followed. The dietary manager acknowledged that staff did not change gloves or perform hand hygiene as often as required and was unable to recite the correct hand washing procedure. These failures in food safety and sanitation practices had the potential to affect all residents in the facility.
Failure to Implement Effective Infection Control Program and Precautions
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP), as well as to update IPCP policies annually. The Infection Preventionist (IP) was unable to demonstrate infection surveillance for symptomatic residents who had not been diagnosed with an infection and lacked methods for investigating infections. The IP tracked only residents prescribed antibiotics, without documenting symptoms or using established criteria to determine infections. The IP also did not investigate the origin of infections, analyze clusters, or determine the organism and source of infection. Employee illnesses were not tracked prior to January 2025, and there was no correlation monitoring between resident and employee illnesses. The facility's Infection Control Committee (ICC) was not active, and required meetings and policy reviews were not conducted. Several IPCP policies and procedures were outdated and had not been reviewed or updated annually as required. The facility also failed to implement enhanced barrier precautions (EBP) and proper hand hygiene during resident care and medication administration. For one resident with multiple unhealed wounds and a recent surgical amputation, staff did not wear protective gowns during high-contact care activities, despite clear signage and physician orders for EBP. Staff members, including a CNA, RN, occupational therapist, and physical therapist, were observed providing care without the required protective equipment. The CNA was unaware of the reason for EBP signage and could not distinguish between transmission-based precautions and EBP. Additionally, an LPN was observed repeatedly failing to perform hand hygiene before and after administering oral and inhaled medications to multiple residents. The LPN donned gloves without sanitizing hands and did not perform hand hygiene after glove removal or between medication passes, contrary to facility policy. The LPN acknowledged forgetting to perform hand hygiene during medication administration. Facility policies required handwashing before and after medication administration, but these procedures were not followed during the observed medication passes.
Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for three residents by not ensuring timely meal service. During the lunch period, three staff members were observed receiving lunch trays before all residents had been served, contrary to facility policy. Observations and interviews revealed that some residents remained in their rooms without having received their meals well after lunch service had begun. One resident, who was dependent on staff for all activities of daily living and unable to speak due to medical conditions including Huntington's disease and aphasia, was observed expressing hunger and did not receive a meal until over two hours after lunch service started. Another resident with moderate cognitive impairment and a third resident with intact cognition both reported being hungry and not having received their lunch during the observation period. Staff interviews confirmed that the affected residents had not yet received their meals due to staff being occupied with other residents. The Director of Nursing and Dietary Manager both acknowledged that staff should not receive meals before all residents are served, and the facility's policy requires prompt delivery of food to ensure safe, palatable, and high-quality meals. The failure to follow this policy resulted in residents experiencing frustration and helplessness while waiting for their meals.
Failure to Assess Respiratory Status Before and After Inhaler Administration
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), who was cognitively intact, reported feeling short of breath and requested her inhaler. The LPN on duty administered two puffs of albuterol inhaler to the resident in the hallway without performing a respiratory assessment prior to administration. No baseline lung sounds or oxygen saturation (O2 sat) were obtained before giving the medication, and no assessment was conducted after administration to determine the effectiveness of the treatment. Further review of the electronic medication record and medication administration records showed no documentation of a respiratory assessment or O2 sat for the resident on the day in question. The LPN acknowledged that an assessment should have been completed both before and after administering the inhaler. The Director of Nursing confirmed that nursing staff are expected to conduct respiratory assessments for residents reporting shortness of breath and when administering as needed inhaled medications. The facility's policy on medication administered by inhaler did not include instructions for obtaining respiratory assessments before or after administration.
Failure to Ensure Immediate Access to Residents' Code Status in Emergencies
Penalty
Summary
The facility failed to ensure that residents' code status, specifically Do-Not-Resuscitate (DNR) orders, were clearly communicated and readily accessible to staff in the event of an emergency. For three residents with advanced directives, the DNR status was not entered as a physician's order or displayed in the designated code status bar within the electronic medical record (EMR). Instead, the DNR documents were filed under the miscellaneous tab, making them difficult and time-consuming for staff to locate during an emergency. In one instance, an LPN was unable to quickly find the code status for a resident, requiring several minutes to search through the EMR and ultimately referencing a paper binder kept in the DON's office, which was not immediately accessible. The residents involved had significant medical conditions, including Huntington's Disease, vascular dementia, adult failure to thrive, and encephalopathy, and were either totally incapacitated with court-appointed guardians or had signed their own DNR orders. Despite the presence of properly executed DNR documents, the lack of proper documentation and visibility in the EMR and other accessible locations meant that staff could not promptly determine residents' code status. The facility's policy required DNR orders to be documented in the resident's chart for staff awareness, but this was not consistently followed, as observed during staff interviews and record reviews.
Failure to Obtain and Review Required Lab Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that laboratory results were obtained and reviewed as ordered to monitor for adverse effects of antipsychotic medications for a resident with severe cognitive impairment and diagnoses including dementia, seizure disorder, and schizophrenia. The resident had active orders for clozapine, which requires regular monitoring with a complete blood count (CBC) with differential every 30 days. However, the electronic medical record showed a gap in laboratory results, with the most recent CBC dated 12/27/2024, and no results for February and March 2025, despite the resident no longer being on hospice and the physician's order to continue monthly monitoring. Interviews revealed that the missed laboratory testing was due to staff failure to obtain the resident's blood sample, with the Director of Nursing stating that when staff are too busy or unwilling, the task is not completed and eventually disappears from the task list without being reported. This resulted in the resident not receiving the required monthly laboratory monitoring for two consecutive months while continuing to receive clozapine and other psychotropic medications.
Failure to Implement Pharmacy Recommendations and Timely Lab Orders
Penalty
Summary
The facility failed to ensure timely review and implementation of Medication Regimen Reviews (MRRs) and pharmacy recommendations for one resident. The resident, who had diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety, was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). A pharmacy consultation recommended lab draws for A1C and magnesium levels, which the physician agreed to and signed. However, a review of the resident's medical records, medication and treatment administration records, and progress notes from October through December revealed that no labs were ordered or drawn, and there was no documentation of these labs being completed. Further review showed that a physician order for routine A1C labs was entered, but the required A1C lab for September was not scheduled or drawn, despite the last A1C being completed in March. The Director of Nursing (DON) acknowledged that lab draws were missed due to issues with order entry duration and communication lapses among travel nurses, resulting in the oversight. Additionally, a subsequent pharmacy consultation again requested updated lab values, but there was no evidence that this was addressed. Facility policy requires timely correction and documentation of pharmacy recommendations, which was not followed in this instance.
Significant Medication Error Due to Nurse Distraction
Penalty
Summary
A medication error occurred when a nurse administered another resident's medications to Resident #10, who had diagnoses including hypertension, diabetes, stroke, and depression, and was assessed as cognitively intact and independent with most activities of daily living. The incident took place during a medication pass when multiple residents were present at the medication cart, asking questions, which distracted the nurse. As a result, Resident #10 received Depakote 125 mg, Seroquel 50 mg, and vitamin D3 25 mcg, which were not prescribed to her. Following the administration of the incorrect medications, Resident #10 became lethargic and experienced confusion, as reported by both the resident and documented in the medical record. The facility's incident report confirmed the error and noted a change in the resident's condition, specifically lethargy for the majority of the shift. The facility's medication administration policy emphasized the importance of verifying the right resident and right medication, and cautioned against interruptions during medication passes, but these procedures were not followed at the time of the incident.
Deficient Pneumococcal Vaccine Education, Consent, and Administration
Penalty
Summary
The facility failed to properly educate residents or their representatives on the currently available and CDC-recommended pneumococcal vaccines for two individuals. In both cases, the immunization consent forms signed by the residents' representatives did not specify which Vaccine Information Statement (VIS) was provided, nor did they include information about the PCV15, PCV20, or PCV21 vaccines. Instead, the forms referenced outdated recommendations and vaccines, such as PCV13 and PPSV23, which are no longer recommended for routine use among adults aged 65 and older. There was also no documentation in the electronic medical records by the physician or Infection Preventionist regarding any discussions or education provided about the benefits or risks of pneumococcal vaccination. Additionally, the facility did not administer a pneumococcal vaccination or document any clinical reasons for withholding it for one resident, despite the legal guardian having provided consent for the vaccination more than two months prior. The resident's medical record lacked any documentation of contraindications or clinical considerations for not administering the vaccine. The Infection Preventionist confirmed that the vaccination had not been given and that the process was still ongoing, with no further explanation or documentation provided. The facility's vaccine consent forms and immunization policies were also found to be outdated, referencing vaccines and recommendations that are no longer current according to the CDC. The standing orders and immunization policy documents did not reflect the most recent guidance, which recommends the use of PCV15, PCV20, or PCV21 for adults at risk. The most current VIS, which includes updated recommendations, was not provided to the residents or their representatives, resulting in a lack of informed decision-making regarding pneumococcal vaccinations.
Failure to Conduct Regular Skin Assessments
Penalty
Summary
The facility failed to conduct regular skin assessments for a resident, leading to a deficiency in quality of care. The resident, who was admitted with diagnoses including ischemic cardiomyopathy and type two diabetes, had a documented history of skin breakdown and redness in skin folds. Despite this, the facility did not perform weekly skin assessments as required by their policy. The resident and her guardian reported consistent redness and irritation in her skin folds, which the facility did not address. Interviews with facility staff revealed that skin assessments were supposed to be conducted weekly and documented in the Treatment Administration Record (TAR) and the electronic medical record (EMR). However, the only documented skin assessment for the resident was on 10/26/24, shortly after admission, with no further assessments recorded. The Director of Nursing confirmed the lack of documentation and acknowledged the resident's history of skin issues, indicating a failure to adhere to the facility's skin integrity policy.
Resident Burned by Hot Soup Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a serious burn injury to a resident who was served hot soup and left unattended. The resident, who had moderate cognitive impairment and was drowsy at the time, attempted to feed herself and spilled the soup, resulting in a second-degree burn on her upper torso. The soup was served at a temperature of 173 degrees Fahrenheit, which was hot enough to cause burns. The resident was found in a reclined position with the soup spilled on her abdomen, and the incident was reported by a Certified Nursing Assistant (CNA) who had left the tray unattended. Interviews with staff revealed that the resident was not positioned correctly for eating in bed, as she was reclined at approximately 45 degrees instead of being upright. The facility's Director of Nursing (DON) confirmed that the tray table should have been moved to the side, and the resident should have been placed in an upright position to prevent such accidents. The facility's policy on burns required an assessment for burn potential on admission and quarterly, but no such assessment was found in the resident's electronic medical record prior to the incident.
Unauthorized Removal of Resident by Former CNAs
Penalty
Summary
The deficiency reported by surveyors involved the facility's failure to prevent the unauthorized removal of a resident, Resident #9 (R9), from the facility by two former terminated Certified Nurse Aides (CNAs). The incident occurred on 9/18/23 when the former CNAs took R9 out of the facility to an unknown location for approximately 16 hours without authorization or necessary medications, including hospice medications and a thickening agent for R9's prescribed therapeutic diet. Despite being on hospice services and having severely impaired cognition, R9 was taken out without proper consent or supervision, posing a risk of serious harm or death. The facility's staff, including the former Director of Nursing (DON) and Registered Nurses (RNs), failed to follow protocols for residents going on a leave of absence, which required authorization from the responsible party or guardian. The facility's lack of oversight and communication led to a situation where R9's whereabouts were unknown for an extended period, causing distress to R9's guardian and raising concerns about the resident's safety and well-being. Additionally, the facility did not have a physician's order for R9's leave of absence, indicating a lack of proper documentation and adherence to established procedures.
Fall and Elopement Risks Due to Inadequate Supervision and Assessments
Penalty
Summary
The report details multiple deficiencies identified during the survey of a long-term care facility. One significant deficiency involved a resident (R24) who sustained a fall resulting in injuries due to the facility's failure to implement appropriate interventions to prevent falls. R24, a resident with moderate cognitive impairment and a history of falls, was found on the floor after falling in the women's common bathroom. Despite being identified as a moderate fall risk with poor safety awareness, R24 did not have a completed Fall Risk Assessment during their stay at the facility. The incident highlighted a lack of proper supervision and intervention to prevent falls for residents at risk. Another deficiency outlined in the report pertained to a resident (R17) with vascular dementia who eloped from the facility multiple times, posing a risk of falls and injury. R17's cognitive intactness and history of wandering behaviors were not adequately addressed by the facility, leading to instances where R17 attempted to leave the facility and engage in potentially unsafe behaviors. The lack of effective supervision and interventions to prevent elopement for residents with wandering tendencies was evident in this case.
Expired Food in Kitchen Refrigerators
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not disposing of expired food in kitchen refrigerators. During an observation at 10:00 a.m. on the specified date, six expired containers of juice were found in the reach-in refrigerator, with expiration dates as far back as February 2024. None of the juice containers had a received date labeled on top. The Kitchen Manager acknowledged that he had recently checked the refrigerators for expired foods but had missed these juices. This failure to properly date and dispose of expired food items is a violation of the FDA Food Code 2017, which mandates that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with the date by which it should be consumed, sold, or discarded.
Deficient Administration and Oversight in LTC Facility
Penalty
Summary
The facility failed to administer its policies, practices, and procedures effectively and efficiently, impacting the well-being of all 22 residents. The Nursing Home Administrator (NHA) was not present during the delivery of an Immediate Jeopardy (IJ) regarding resident abuse, despite being informed earlier by state surveyors. Additionally, the facility administration did not report and investigate an unauthorized leave of absence (LOA) of a resident, resulting in the resident's location being unknown for approximately 16 hours without necessary medical supplies and equipment, including hospice medications. This led to undetected abuse and potential psychosocial harm to the residents. The facility administration also failed to provide adequate support, training, and oversight to the staff. The former Director of Nursing (DON) reported a lack of communication and support from the administrative staff, who were often absent from the facility. The DON also mentioned that the new social worker was overwhelmed and not properly trained, leading to missed mental health services for a resident with violent behaviors and self-harm statements. Additionally, the MDS Coordinator/Former Infection Preventionist (IP) was terminated abruptly, further indicating a lack of effective management and support. The facility administration did not ensure that the IP completed the required specialized training in infection prevention and control, placing the entire facility population at risk for infectious disease outbreaks. The administration also failed to implement the Smoking Policy and Procedure for two residents, compromising the safety of residents, visitors, and staff. Furthermore, the administration did not maintain an effective abuse and dementia management training program, resulting in an Immediate Jeopardy when a resident was taken from the facility without the guardian's knowledge and a resident-to-resident altercation occurred. The facility's policies and procedures were not reviewed and updated as required, contributing to these deficiencies.
Failure to Ensure Infection Preventionist Completed Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training in infection prevention and control. The MDS Coordinator, who served as the IP from January 2023 through March 2024, did not finish the necessary training despite starting the certification process. During an interview, the MDS Coordinator admitted to struggling with the certification process and ultimately did not complete it. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the MDS Coordinator did not have the required certification and cited time constraints as her excuse for not completing the training. On the day of the scheduled Infection Control (IC) meeting, the MDS Coordinator was observed leaving the facility abruptly, indicating she had been terminated and would not participate in the meeting. The current IP, who received her certification in March 2024, was training under the MDS Coordinator until her departure. The facility's failure to ensure the MDS Coordinator completed the required IP training resulted in a deficiency, as verified by the DON and NHA. This deficiency was documented in the CMS Form #20054, which mandates that facilities must have a qualified IP with completed specialized training before assuming the role.
Failure to Complete and Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) were completed and that recommendations were reviewed by a physician for five residents. Specifically, for Resident #20, the facility was unable to find the pharmacist's recommendations and the physician's response for the months of October and November 2023. Similarly, for Resident #21, the facility could not locate the pharmacist's recommendations and the physician's response for the months of November 2023 and January 2024. Resident #6 also had missing pharmacist recommendations and physician responses for multiple months, including September, October, December 2023, and February 2024. For Resident #4, the facility did not document any reports to the attending physician or Director of Nursing (DON) for several months, despite the pharmacist making recommendations. The DON was unable to locate the pharmacy recommendations and stated that the protocol was to upload these records to the resident's electronic medical record (EMR). The facility also failed to provide a policy regarding MRRs when requested by the surveyor. This lack of documentation and follow-up indicates a systemic issue in the facility's handling of MRRs and pharmacist recommendations.
Failure to Ensure Resident Rights Training
Penalty
Summary
The facility failed to ensure the provision of resident rights training requirements for three of seven employees reviewed. Specifically, the Nursing Home Administrator and a Registered Nurse had not completed the required resident rights training within the 12-month period, with their last training completed on 2/1/23. Additionally, an Agency Certified Nurse Aide had not completed any resident rights training. During an interview, the Director of Nursing stated that she was responsible for annual training and competencies and that the facility conducts training based on the calendar year. The DON also mentioned that the agency staff should have completed the training through their agency, but confirmed that the Agency CNA had not completed specific training for this facility. The facility's Resident Abuse, Neglect, Mistreatment, or Misappropriation Prevention Program mandates that all staff and volunteers be in-serviced upon employment and at least annually thereafter regarding Resident's Rights.
Failure to Ensure Residents Were Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, R15 and R20, were free from physical restraints imposed for purposes of convenience. R15, who had diagnoses including dementia, anemia, kidney disease, and constipation, was observed with a tab alarm clipped to the back of her shirt while sitting in a reclining chair. The review of R15's electronic medical record (EMR) found no physical order, signed consent, or restraint assessment, despite the care plan indicating the use of a tab alarm. R15's responsible party was listed as a guardian, but there was no documentation of consent from the guardian for the use of the restraint. Similarly, R20, who had diagnoses including dementia, aphasia, and cerebral infarct, was observed without a tab alarm clipped to his shirt on multiple occasions, despite the care plan indicating its use. The review of R20's EMR also found no physical order, signed consent, or restraint assessment. R20's responsible party was his spouse, but there was no documentation of consent for the use of the restraint. The Director of Nursing confirmed that all alarms need a consent from the resident or guardian, a physician order, and should be care planned and reassessed quarterly, which was not done in these cases.
Failure to Report Unauthorized Leave of Absence Timely
Penalty
Summary
The facility failed to ensure an unauthorized leave of absence (LOA) was reported timely to the facility administrator and State Agency (SA) for one resident. Resident #9, who had severe cognitive impairment and was under hospice care, was taken out of the facility overnight by two former CNAs without the guardian's permission. The guardian was not informed until the following morning, causing significant distress and concern for the resident's safety. The progress notes revealed that the resident was taken out of the facility at 6:07 PM, and attempts to contact the guardian were made later that night but were unsuccessful. The resident returned the next morning, and the facility staff, including the Director of Nursing (DON) and Nursing Home Administrator (NHA), were unaware of the resident's absence until they arrived at work. The facility's failure to notify the guardian and the appropriate authorities in a timely manner was a significant oversight. Interviews with the staff indicated a lack of clarity and communication regarding the resident's leave. The former DON admitted to not notifying the NHA immediately due to previous instructions not to bother them. The NHA confirmed that the incident was not reported to the SA as required by the facility's policies. This incident highlights a breakdown in the facility's procedures for managing and reporting unauthorized absences, especially for residents with severe cognitive impairments and under hospice care.
Failure to Investigate Incident of Abuse/Neglect
Penalty
Summary
The facility failed to investigate an incident of abuse/neglect involving a resident with severe cognitive impairment and multiple medical conditions, including Huntington's disease and aphasia. The resident was taken out of the facility overnight by two former CNAs without the permission of the resident's guardian. The guardian was not informed until the following morning, causing significant distress and concern for the resident's safety and well-being. The progress notes and interviews with staff and the guardian revealed that the facility did not follow proper procedures for obtaining permission for a leave of absence (LOA) and failed to notify the appropriate parties in a timely manner. The resident's responsible party was not contacted until after the resident had already left the facility, and multiple attempts to reach the former CNAs and the guardian were unsuccessful. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unaware of the resident's absence until the next morning, and local law enforcement was eventually involved. The facility's policies on abuse investigation and incident/accident reporting were not followed. There was no documented investigation summary of the incident, and the State Agency (SA) was not notified. The NHA and DON confirmed that the incident was not properly discussed in Quality Assurance and Performance Improvement (QAPI) meetings, and no appropriate corrective action was taken. The failure to investigate and report the incident as required by facility policy and regulatory standards constitutes a significant deficiency in the facility's handling of abuse/neglect allegations.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to notify two residents in writing about the reasons for their transfers to the hospital. Resident 18 was transferred to the hospital on 7/7/23 and returned to the facility on an unspecified date, but there was no written notification of the transfer provided to her. Similarly, Resident 20 was transferred to the hospital on 6/19/23 and returned to the facility on an unspecified date, also without receiving written notification of the transfer. The facility's policy requires written notification of transfers to be provided to residents and their representatives, but this was not followed in these cases. During an interview, the Director of Nursing in Training confirmed that the facility did not follow its transfer notification policy, citing the small size of the building and the practice of notifying residents and their representatives individually. The facility's policy, reviewed on 1/30/24, mandates that written notice of pending involuntary transfers or discharges be provided to residents, with additional copies filed in the resident's chart and sent to relevant parties. The policy also requires documentation of the transfer or discharge in the resident's medical record and communication of appropriate information to the receiving healthcare institution or provider.
Failure to Provide Written Bed Hold Information
Penalty
Summary
The facility failed to ensure written information was provided to residents or their representatives regarding bed hold policies during hospital transfers or therapeutic leaves. Specifically, three residents (R18, R20, R24) were transferred to hospitals on various dates, and in each case, there was no Bed Hold Authorization form completed in their Electronic Medical Records (EMR). This resulted in the residents and their representatives being unaware of potential expenses related to reserving their beds during their absence from the facility. Interviews and record reviews revealed that the facility did not follow its policy regarding bed holds and transfers. The Director of Nursing in training acknowledged that the facility did not have a specific bed hold form and admitted that they typically notify residents or their representatives individually. The facility's policy, revised in 2002, mandates informing residents of their rights and obligations during temporary absences, but this was not adhered to in the cases reviewed. The lack of proper documentation and notification represents a significant deficiency in the facility's compliance with regulatory requirements.
Failure to Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a quarterly Minimal Data Set (MDS) assessment for one resident (R15) within the required timeframe. R15, who was admitted to the facility with diagnoses including dementia, anemia, kidney disease, and constipation, was dependent on staff for various activities of daily living. The last MDS assessment for R15 was completed on 10/11/23, and the next assessment was due on 2/10/24. However, no updated MDS assessment was found, and the facility could not provide one during the survey. This indicates that the quarterly MDS assessment was overdue by more than two months at the time of the survey on 4/25/24. During an interview, the Licensed Practical Nurse (LPN) responsible for MDS assessments stated that she uses the electronic medical record (EMR) scheduler and the Resident Assessment Instrument (RAI) tool to keep track of assessment due dates. Upon checking the EMR, the LPN discovered that R15 was not scheduled on the scheduler, which she attributed to a possible deletion error. The LPN acknowledged that R15's quarterly MDS assessment was overdue and expressed the need to start the assessment immediately. The facility was unable to provide a policy for MDS assessments when requested by the surveyor.
Failure to Complete and Send PAS/ARR Documentation
Penalty
Summary
The facility failed to ensure that the Preadmission Screening (PAS)/Annual Resident Review (ARR) documents were reviewed, revised, and sent to the local state agency for a resident with mental illness and dementia. The resident, who was admitted with diagnoses including dementia with behavioral disturbance, depression disorder, and bipolar disorder, had an Annual Minimum Data Set (MDS) assessment indicating mild cognitive impairment. Despite the PAS/ARR Level I screening marking the resident as having a current diagnosis of mental illness or dementia and receiving treatment for the same, the required DCH-3878 form was not completed or sent to the local Community Mental Health Services Program (CMHSP). This oversight was discovered during a review of the resident's Electronic Medical Record (EMR). The Social Services Director, who had been recently employed and in her position for only three weeks, was unable to explain the missing form for the resident. The deficiency was identified through an interview and record review, revealing that the facility did not comply with the requirement to send the necessary documentation to the local CMHSP. This failure potentially excluded the resident from receiving necessary care and services appropriate to meet their mental health needs. The Social Services Director acknowledged the oversight but could not provide an explanation due to her recent employment and limited time in the position.
Failure to Develop Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with multiple medical diagnoses, including depression, bipolar disorder, paraplegia, and pressure ulcers. During an interview, the resident confirmed that the facility was treating his wounds, which were still open and undergoing treatment. However, there was no transmission-based precaution signage outside the resident's room to alert staff of the enhanced barrier precautions required due to the open wounds. Additionally, the resident's care plan did not include focus areas, goals, or interventions related to his smoking habits or his severe allergy to bee stings, despite the resident's history of anaphylactic reactions to bee stings and his unsupervised smoking outdoors. The resident was observed to have a lock box in his room, which he did not use, and kept his cigarettes and lighter in his jacket pocket. The resident's progress notes indicated that he had been smoking outdoors unsupervised and had received cigarettes and vape pens from his brother. The Director of Nursing (DON) was unaware of the resident's severe allergy to bee stings and the lack of emergency medication orders to counteract an anaphylactic reaction. The care plan was not updated to reflect the resident's allergy and smoking habits, leading to a deficiency in providing a comprehensive, resident-centered care plan.
Failure to Assess and Obtain Consent for Mobility Bars
Penalty
Summary
The facility failed to assess, reassess, obtain consent, and develop care plan interventions for a resident. An observation was made of the resident in her room sitting in her wheelchair, with two side rails/mobility bars on the upper half of each side of her bed. The resident stated she was not aware of signing a consent for the mobility bars. The physician's order indicated the use of mobility assist bars, but the resident's Minimum Data Set (MDS) admission assessment and subsequent quarterly assessments lacked any indication of the use of a bed rail or mobility bar. Additionally, the resident's care plan did not include an intervention for the use of mobility bars or an assessment/reassessment for their use.
Failure to Follow Physician Orders and Provide Emergency Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with dementia, aphasia, and cerebral infarct. The resident was observed multiple times without the prescribed [NAME] hose while seated during the day. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that the staff were unaware of the resident's need for the [NAME] hose, and the order remained active in the electronic medical record (EMR) without being followed or discontinued if no longer needed. Another resident, who was cognitively intact and had a history of severe allergic reactions to bee stings, was observed smoking outside the facility unsupervised. The resident's medical records indicated an allergy to bee stings, but there was no physician order for emergency medication to counteract an anaphylactic reaction. Interviews with the RN and DON confirmed that they were unaware of the resident's need for such medication, and the resident was not provided with the necessary emergency medication or supervision while outdoors. The facility's failure to follow physician orders and obtain necessary emergency medication for residents demonstrates a lack of adherence to medical directives and inadequate resident care. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in communication and oversight among the facility's staff.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to mitigate triggers that may cause re-traumatization for a resident (R6) who has a history of PTSD suspected from childhood sexual abuse. R6 expressed concern about another male resident who constantly yells out, which scares her. Despite this, the facility's social worker, who started three weeks prior, was unaware of R6's PTSD history and had not conducted a social service assessment to identify potential triggers. The care plan interventions for R6 were deemed inappropriate by the social worker, who acknowledged the need for more effective interventions. R6's medical records indicated diagnoses of dementia with behavioral disturbance, major depressive disorder, and bipolar disorder. Her care plan included a history of severe chronic bipolar disorder and PTSD, with interventions to provide a calming environment. However, the facility's trauma-informed care policy and procedure were not followed, as the social worker had not assessed R6 for trauma exposure or developed a plan of care to address her symptoms. The facility's policy required training for all employees on trauma-informed care, which was not evident in this case.
Failure to Ensure Proper Assessment and Consent for Bedrails
Penalty
Summary
The facility failed to ensure appropriate assessment, measurements, and consent for bedrails for one resident (R5). On 4/23/24, an observation revealed that R5's bed had two side rails/mobility bars, and R5 was unaware of having signed a consent for them. A review of R5's electronic medical record (EMR) showed no evidence of consent, gap measurements, or assessment for the mobility bars. The Director of Nursing (DON) confirmed that consent and assessment were required but could not provide the necessary documentation by the time of the exit on 4/25/24. R5's physician order dated 2/22/23 indicated the use of mobility assist bars, but the complete EMR lacked documentation of consent, assessment, re-assessment, and gap measurements. Additionally, R5's Minimum Data Set (MDS) admission assessment and subsequent quarterly assessments did not indicate the use of bed rails or mobility bars. The facility's policy on bed rails, dated 4/23/24, required a comprehensive assessment, medical need determination, and informed consent, none of which were documented for R5.
Failure to Coordinate Behavioral Health Services
Penalty
Summary
The facility failed to coordinate behavioral health services for a resident with severe cognitive impairment and multiple behavioral health diagnoses, including recurrent major depressive disorder, dementia, and delusional disorders. The resident was observed multiple times sleeping in a dark room and exhibited violent behaviors and suicidal ideation. Despite a consultation with a community mental health provider recommending follow-up, no follow-up occurred within the specified timeframe. The resident continued to display severe behavioral symptoms, including suicidal statements, over several months without appropriate mental health intervention. The resident's electronic medical record revealed numerous instances of suicidal ideation and violent behavior, yet there was a significant delay in follow-up consultations with the community mental health provider. The facility's Director of Nursing (DON) admitted that the lack of a trained social worker contributed to the oversight. The new social worker, who was inexperienced and overwhelmed, failed to manage the resident's behavioral health needs effectively. This lack of coordination and follow-up led to the resident's continued distress and unsafe behaviors. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Social Services Director (SSD), confirmed the resident's ongoing behavioral issues and the facility's failure to provide necessary behavioral health services. The facility did not have a behavioral health policy available for review during the survey, further indicating a lack of structured procedures to address such critical needs. The deficiency highlights the facility's failure to ensure the resident received the necessary behavioral health care and services, as required by regulations.
Failure to Ensure Licensed Personnel Administered Medications
Penalty
Summary
The facility failed to ensure that licensed personnel administered medications to a resident. Resident #12, who has diagnoses including schizophrenia and chronic kidney disease, was mistakenly given Miralax by a nursing assistant in training. The Director of Nursing (DON) had prepared the Miralax in a thickened liquid and labeled it with the resident's first name. The nursing assistant, unaware that the cup contained medication, gave it to Resident #12, who consumed it quickly before it could be retrieved. The DON confirmed that CNAs are not permitted to administer medications and could not recall if the attending physician had been notified after the error. The facility's policy on medication error reporting requires prompt notification of the attending physician, implementation of physician's orders, and close monitoring of the resident for 24 to 72 hours. However, a review of Resident #12's electronic medical record did not show any physician communication or evidence of increased monitoring following the error. Additionally, the Medication Administration Record did not contain an order for Miralax at the time of the incident. The Medication Related Incident Report was signed by a physician approximately 11 days after the error occurred.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident diagnosed with Huntington's disease, aphasia, dysphagia, contracture of an unspecified hand, and alcohol abuse. The resident was on a leave of absence from the facility and returned at 9:48 AM. However, the Medication Administration Record (MAR) inaccurately indicated that medications were administered at 8:00 AM, which was not possible as the resident was not present in the facility at that time. The Director of Nursing (DON) confirmed that the medications were not administered at 8:00 AM and should not have been marked as such in the MAR. The facility's policy requires that medication errors be documented in the resident's clinical record and reported to the attending physician. However, there was no documentation of a medication error or evidence of notification to the attending physician in the resident's electronic medical record (EMR). The DON was unable to provide further insight into why the administration of the resident's medications was inaccurately documented or identify the nurse responsible for the error.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with open wounds. Resident #21, who was admitted with medical diagnoses including depression, bipolar disorder, paraplegia, and pressure ulcers, had wounds that were still open and undergoing treatment. Despite this, there was no transmission-based precaution (TBP) signage outside the resident's room to alert staff of the need for EBP. Additionally, a registered nurse was observed performing wound care without wearing proper personal protective equipment (PPE). The infection preventionist acknowledged the need for EBP for the resident but admitted that staff had not been fully educated on the procedures, leading to the lack of proper precautions and signage. The deficiency was further highlighted by the facility's own policy, which mandates the implementation of EBP for the prevention of transmission of multidrug-resistant organisms (MDROs). The policy, dated 4/5/24, was not followed, as evidenced by the absence of TBP signage and the improper use of PPE during wound care. The infection preventionist's admission that staff education was incomplete underscores the facility's failure to adhere to its own infection control protocols, thereby compromising the safety and care of the resident.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to ensure that an eligible resident was offered influenza vaccines as recommended by the CDC. Resident #20, who has diagnoses including cerebral infarction, dementia, and aphasia, was admitted to the facility with a BIMS score of 8, indicating moderate cognitive impairment. A review of the resident's vaccination history revealed that the last dose of the seasonal influenza vaccine was administered on 10/30/20, and the status for eligible vaccinations indicated that the seasonal influenza vaccine was due. Interviews with the Current Infection Preventionist and the Director of Nursing in training confirmed that there was no documentation of an influenza vaccine offering for the resident in the previous three years. The CDC recommends routine annual influenza vaccination for all persons aged 6 months and older who do not have contraindications, ideally offered during September or October. However, the facility failed to document any offering or administration of the influenza vaccine to Resident #20 for the past three years, despite the resident being eligible and the vaccine being due. This deficiency was identified through interviews and record reviews conducted by the surveyors.
Failure to Maintain Effective Abuse and Dementia Management Training Program
Penalty
Summary
The facility failed to maintain an effective abuse and dementia management training program for three out of seven staff members reviewed for annual training. Specifically, the Nursing Home Administrator (NHA) and a Registered Nurse (RN) had not completed the required abuse, neglect, and exploitation training and competency evaluation within the required 12-month period, with their last training completed on 2/1/23. Additionally, an Agency Certified Nurse Aide (CNA) had not completed the facility's abuse training program. Furthermore, the NHA and the same CNA had not completed the required dementia training, with the NHA's last training also completed on 2/1/23. The Director of Nursing (DON) confirmed that the facility conducts training based on the calendar year and acknowledged that the agency CNA should have had training completed by the agency but did not have specific training for this facility. The facility's policy on Resident Abuse, Neglect, Mistreatment, or Misappropriation Prevention Program mandates that all employees and volunteers receive information, training, and ongoing in-services about appropriate interventions for dealing with aggressive or catastrophic reactions of residents, how to report allegations without fear of reprisal, recognizing signs of burnout, frustration, and stress that may lead to abuse, and what constitutes abuse, neglect, and misappropriation of resident property. The policy also requires that all facility staff and volunteers be in-serviced upon employment and at least annually thereafter regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, and misappropriation of property. The failure to adhere to these training requirements was identified during an interview with the DON and a review of staff education records and competencies on 4/25/24.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure the provision of infection control training for four of seven employees reviewed for infection control training. Specifically, the Nursing Home Administrator had a future date listed for training completion, indicating it had not been done. A Certified Nurse Aide (CNA) and the Director of Nursing (DON) did not complete the required Infection Control Annual Inservice. The DON was noted to have been the preventionist for years but no documentation or certificate was provided to confirm her training. Additionally, an agency CNA also did not complete the required Infection Control Annual Inservice. These deficiencies were identified during a review of staff education records and competencies on 4/25/24.
Failure to Protect Resident from Exploitation
Penalty
Summary
The facility failed to protect a resident from potential mental and sexual exploitation by a staff member. The resident, who has intact cognition and diagnoses including quadriplegia, bipolar depression, and traumatic brain injury, was involved in a series of inappropriate social media exchanges with a member of the housekeeping staff. The resident initiated contact with the staff member, and the conversation quickly escalated to discussions of a sexual nature, including the exchange of explicit messages and images. The issue was brought to light by the resident's guardian, who discovered the inappropriate messaging and reported it to the facility. Despite attempts to contact the staff member involved, the facility was unable to reach them initially due to disconnected phone numbers and a full voicemail box. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that such relationships between staff and residents are not permitted. The identity of the staff member was verified through social media profiles, confirming their involvement in the inappropriate exchanges.
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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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