Marshall Nursing And Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshall, Michigan.
- Location
- 575 N Madison Street, Marshall, Michigan 49068
- CMS Provider Number
- 235174
- Inspections on file
- 34
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Marshall Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with dementia and anxiety repeatedly refused a scheduled shower, but a CNA proceeded after being told by an RN that the shower had to occur regardless of the resident’s objections. During transfer with a mechanical lift and use of a shower chair, the resident became combative, and one CNA held the resident’s wrists down while the other completed the shower, which a second CNA later characterized as abuse. The resident kicked or struck a shower bar or lift bar, developed bruising, swelling, and an abrasion from the knee to the ankle on the right leg, and an X-ray confirmed an acute transverse fibular neck fracture. The resident’s guardian was informed of a bruise and that the resident had been combative, and later learned of the resident’s unexpected death.
A resident with dementia and other psychiatric diagnoses was scheduled for a shower and repeatedly stated she did not want it, but CNAs proceeded after being told by an RN that the shower had to be given. During the transfer with a mechanical lift and while on the shower chair, the resident became combative, was held down by the wrists, kicked wall and equipment bars, and subsequently developed bruising, swelling, and an abrasion of the right lower leg; an X‑ray later showed an acute fibular neck fracture. One CNA later stated that holding the resident’s wrists and forcing the shower constituted abuse, and both CNAs documented that the resident did not want the shower. The DON documented the injury and notified the guardian of a bruise and ordered X‑ray, and the resident later died. The Administrator, despite having CNA statements describing the incident, concluded abuse could not be substantiated and did not report the suspected abuse incident to the state agency, resulting in a failure to report as required.
A resident with dementia and other psychiatric diagnoses was given a shower using a mechanical lift and shower chair after repeatedly refusing, per CNAs who reported they were instructed by an RN that the shower had to be done. During the shower, the resident became combative, kicked a wall or lift bar, and staff held the resident’s wrists to prevent hitting, resulting in bruising, swelling, and fingertip marks, with later X-ray confirming an acute fibular neck fracture. One CNA stated that holding the resident’s wrists and forcing the shower was abuse and violated the resident’s rights. Although the DON documented notifying the guardian of a shin bruise and staff documented the incident on a shower sheet, the facility did not complete or provide an incident report or a thorough investigation of the alleged abuse and injury when requested by surveyors.
Surveyors determined that the facility did not follow its own policy and professional standards for managing food brought in by families and visitors and stored in resident refrigerators. During observations with the DON, surveyors found outside delivery pizza boxes without any labeling, dates, expiration dates, or resident names; a bag of tacos from an outside restaurant that was past the facility’s allowed holding time; and a salad with no date or resident identification. They also observed several opened 2L bottles of soda with no dates or resident names. The DON acknowledged that all such items were required to be labeled, dated, and marked with the resident’s name, and policy review confirmed that refrigerated cooked foods must be date-marked and discarded after a set time, and undated foods discarded.
Surveyors found that two residents with indwelling urinary catheters had drainage bags repeatedly observed resting on the floor rather than being properly secured to the bed and kept off the ground, as required by the facility’s infection control expectations and one resident’s care plan. Despite the ICP’s and DON’s stated expectations that catheter bags hang below the resident and never touch the floor, staff allowed the bags to remain on the floor on multiple observations, indicating a failure to maintain appropriate infection prevention and control practices for catheter management.
A resident with severe cognitive impairment, overactive bladder, and an indwelling urinary catheter had a care plan intervention requiring documentation of catheter output, but staff recorded urine output only a few times during the resident’s stay instead of at least once per shift. CNA staff reported they were supposed to document amounts when emptying catheter bags, and the DON confirmed that catheter output should be recorded every shift. Nursing notes later described the catheter not draining, unsuccessful flushing attempts, and the need to replace the Foley, after which a significant amount of dark yellow urine with sediment was immediately drained, demonstrating that the ordered monitoring intervention was not consistently carried out.
A resident with multiple comorbidities and a MRSA-infected wound did not consistently receive physician-ordered daily wound treatments, as evidenced by over 30 missed treatments and incomplete documentation in the MAR. Weekly wound assessments were also missing on several occasions. Staff interviews confirmed that wound care and documentation were not performed as required, and the resident reported inconsistent dressing changes to wound clinic staff.
Staff failed to keep a resident's controlled medication, Lorazepam 0.5mg, in its original pharmacy packaging and instead repackaged the tablets into multiple unlabeled clear bags and a cup. The repackaged medication lacked required labeling such as resident name, medication name, and directions, and staff could not identify the tablets by appearance. Nursing staff and the DON confirmed the improper storage and labeling, and the individual responsible for the repackaging could not be identified.
The facility did not ensure proper calibration of glucometers or compatibility between glucometers and glucose test strips for residents needing blood glucose monitoring. Staff were unclear about calibration procedures, logs were incomplete or missing, and at least one control result was out of range without documented follow-up. Multiple types of glucometers and test strips were used interchangeably, and the correct control solutions were not always used, leading to improper monitoring practices.
Staff used a ReliOn Premier BLU glucometer, intended for single-patient use only, on multiple residents and cleaned it with unapproved disinfectant wipes, contrary to manufacturer instructions. The DON was unaware of the single-patient restriction, and staff wrapped glucometers in wipes for disinfection, which was not in line with manufacturer guidelines. These practices failed to meet infection prevention and control requirements.
The facility failed to maintain documentation for glucometer calibration, affecting 17 diabetic residents. An LPN stated that glucometers were tested every 24 hours, but the logbook was missing, raising concerns about the accuracy of blood glucose readings. The Regional Nurse confirmed the absence of the logbook, which should have been available for monitoring.
A facility failed to disinfect glucometers between uses, affecting four residents. An LPN was observed performing blood glucose tests without proper disinfection, placing the device on various surfaces without barriers. The LPN cited a lack of germicidal wipes and a hectic environment as reasons for not following protocol. The DON and a Regional Nurse confirmed the risk of infection control breaches, and audits were not available to ensure compliance.
A resident with cognitive impairment and multiple medical conditions developed additional pressure injuries due to the facility's failure to implement proper care interventions. The resident was not repositioned regularly, and pain management was inadequate, leading to severe discomfort and reluctance to move. The pressure-reducing mattress was found unplugged, and a medical device-related pressure injury was identified, indicating a lack of proper care and monitoring.
A resident with multiple pressure ulcers and severe pain did not receive prescribed pain medication consistently, particularly before wound care, leading to uncontrolled pain. Despite having a care plan for pain management, the facility failed to administer Oxycodone as needed, resulting in the resident experiencing severe discomfort and anxiety during care procedures.
The facility did not send notifications of emergency transfers for 41 residents to the State LTC Ombudsman over the past year. The Ombudsman confirmed not receiving any notifications despite inquiries. The RCD could not provide evidence of sent notifications, only a list of transferred residents.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 49 residents. Observations included peeling shrink wrap on cooler doors, soiled kitchen appliances, and inadequate air gaps in plumbing. Kitchenettes also had soiled ventilation grills and light covers. These issues indicate a failure to adhere to food safety standards, increasing the risk of cross-contamination.
The facility failed to maintain the outdoor waste receptacle, affecting 49 residents. The receptacle was missing a rear sliding door and had a cracked swinging door, increasing pest attraction. The Dietary Manager planned to contact the waste removal company for repairs. Facility policy requires regular cleaning and sanitizing of garbage cans, reporting damage for replacement, and maintaining dumpsters covered and clean.
The facility failed to maintain a clean and sanitary environment, affecting 49 residents. Observations included soiled flooring, stained ceiling tiles, and non-functional light bulbs in resident rooms. Common areas had missing vacuum breakers, damaged chairs, and soiled ventilation grills. Maintenance logs lacked documentation of these issues, indicating inadequate follow-up. Policies for housekeeping and maintenance were not effectively implemented, leading to potential cross-contamination and decreased air quality.
The facility failed to provide palatable and temperature-controlled food, affecting 49 residents. Observations showed food temperatures outside safe ranges, and residents reported dissatisfaction with taste and lack of alternative options. The dietary staff acknowledged these issues, and plans for an alternative menu were not yet implemented.
A resident with severe cognitive impairment was observed in a wheelchair with a torn and cracked arm cushion, which was not reported for repair by the LPN. The ADON confirmed no report was made, highlighting a lapse in communication and protocol adherence, posing an infection control issue.
A facility failed to accurately complete an MDS assessment for a resident regarding the use of restraints. The resident, with multiple medical conditions, used side rails for assistance, which were incorrectly coded as restraints in the MDS. Interviews revealed that the side rails were intended as assistive devices, and the MDS Coordinator acknowledged the coding error, indicating a lapse in accurate assessment and documentation.
A resident admitted with complex medical conditions did not receive a baseline care plan within 48 hours as required. Despite being cognitively intact, the resident was unaware of her care plan. Facility staff acknowledged the oversight, noting the plan was completed but not uploaded to the medical record in time, and a crucial part of the plan was incomplete.
A resident with multiple contractures was not provided with necessary splints and braces as per their care plan, potentially worsening their condition. Observations showed the splints were left on a chair instead of being applied. Staff interviews revealed confusion about responsibilities, with CNAs lacking access to printed care plans, leading to inconsistent care delivery.
A facility failed to obtain weights per policy for a resident, leading to potential inaccuracies in assessing the resident's nutritional status. The resident, with multiple diagnoses, experienced significant weight loss and expressed dissatisfaction with the facility's food, often refusing meals. The resident's menu ticket lacked information on food preferences, and the Registered Dietician's request for a reweigh was not completed, contributing to the deficiency.
The facility failed to properly store, clean, and label oxygen and respiratory equipment for two residents, leading to potential cross-contamination and respiratory illnesses. One resident was observed with undated oxygen tubing and unbagged nebulizer equipment, while another had a nasal cannula lying on bed linens. The ADON/ICN noted that equipment should be changed and stored correctly, highlighting a lapse in infection control practices.
A facility failed to maintain effective communication with a contracted dialysis center, resulting in incomplete documentation of a resident's dialysis care and weight tracking. The resident, with end-stage renal disease, had an order for weekly weights, but inconsistencies in weight documentation were noted. The dialysis center did not consistently complete communication forms, leading to a deficiency in monitoring the resident's condition.
A facility failed to assess and measure bed rails for a resident, risking entrapment. The resident, with multiple health issues, used side rails for mobility. Staff admitted to not measuring the rails, despite policy requirements for assessments at installation and quarterly.
A facility experienced a 16% medication error rate due to improper administration practices. An RN gave a sublingual medication orally mixed with pudding, and another RN administered Flomax before breakfast and failed to ensure a resident swallowed their medication. Additionally, the RN did not prime an insulin pen before use, citing unfamiliarity with the facility's procedures as a travel nurse.
The facility failed to secure medication and treatment carts, with two carts found unlocked and containing prescribed medications. Additionally, an RN left a medication cart unlocked and a computer with a resident's medical record exposed while administering medications, compromising security and confidentiality.
The facility failed to offer alternative food choices, leading to dissatisfaction among residents. A resident reported refusing meals due to unappealing food, with only a peanut butter and jelly sandwich as an alternative. Another resident was unaware of other options, and a third resident noted the absence of an alternative menu despite promises. Observations confirmed the unappetizing nature of meals served.
A facility failed to coordinate hospice services for a resident with COPD and dementia, resulting in potential inadequate care. The resident was not provided with a hospice calendar, and the facility's hospice notebook lacked a complete plan of care and visit schedule. The ADON could not provide necessary documentation, and the SW confirmed a delay in documenting a care conference with the hospice agency.
A facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter, designed to reduce transmission of multidrug-resistant organisms. Despite signage indicating EBP requirements, an LPN and a CNA did not wear isolation gowns during high-contact care activities. The DON confirmed the oversight and acknowledged the need for gown use in addition to gloves.
A resident was left exposed during a catheterization procedure, and an RN made inappropriate comments and refused to provide necessary care. The RN was terminated for these actions.
The facility failed to develop comprehensive pressure ulcer care plans for two residents. One resident managed his own wound care due to lack of staff intervention, and another resident's pressure ulcer was not documented or addressed in her care plan.
The facility failed to document a lab order and resident assessment for a resident with severe diagnoses, did not administer medications as ordered for another resident, and did not maintain infection control during a catheterization procedure. These deficiencies were identified during a survey and confirmed by the Director of Nursing.
The facility failed to provide necessary treatment and services for pressure ulcers for three residents, leading to deficiencies in care. One resident had to perform his own dressing changes due to lack of staff intervention, another resident's pressure ulcer was not documented or treated in a timely manner, and a third resident did not receive consistent and appropriate wound care, including the use of incorrect cleansing solutions.
Failure to Prevent Physical Abuse and Honor Refusal of Shower Leading to Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to refuse care during a shower. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who had been reported by her guardian as being in her normal state prior to the incident and without prior reports of a change in condition. On the day in question, the resident was scheduled for a shower. According to interviews and documentation, when CNAs entered the resident’s room with a mechanical lift and shower chair and placed the sling under her, the resident became combative, yelled that she was not supposed to receive a shower, and repeatedly stated she did not want the shower. Despite the resident’s repeated refusals, CNA F reported that she proceeded with the shower because RN H told her that the resident had to be showered or she would be written up, and that “no matter what” the resident was going to get a shower. Both CNAs described the resident as combative, digging into their skin, hitting, and kicking. CNA F stated she held the resident’s arms down by the wrists while CNA G washed the resident, and CNA G confirmed she saw CNA F holding the resident’s wrists to prevent the resident from hitting her. CNA G later stated that holding the resident’s wrists down and forcing the shower despite the resident’s refusal constituted abuse and that the shower should not have been given once the resident clearly refused. During the course of this forced shower, the resident sustained an injury to her right lower leg. Accounts from staff varied slightly, with CNA F and CNA G reporting that the resident kicked a bar on the wall in the shower room and/or the mechanical lift bar, and RN H reporting that the resident hit her leg on the mechanical lift bar when being transferred. Post-incident documentation by RN H described bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, yelling out with touch, and refusal of range of motion of the knee. A progress note by the DON documented that the resident became aggressive during the shower and hit her leg on the shower chair, resulting in a bruise, and an X-ray subsequently showed an acute transverse fibular neck fracture of the lower leg. The resident’s guardian was notified of the bruise and told that the resident had been combative during the shower, and later learned of the resident’s death, which she described as a shock given that she had not been informed of any change in condition prior to that day.
Failure to Report Suspected Abuse Related to Forced Shower and Resulting Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to report to the state agency an allegation of abuse related to a resident who was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety. The resident had been admitted and later returned to the facility, and subsequently expired with a physician-documented time of death of 3:34 PM (actual time 2:34 PM). On the day of death, a progress note documented that the ADON was on the phone with the resident’s guardian discussing a change in condition and an assessment by the Medical Director when two CNAs reported they believed the resident had passed away. The ADON assessed the resident and found her unresponsive, with fixed eyes, no visible breathing, no lung sounds, and no apical pulse after a full 60‑second check, and the Medical Director then confirmed death at 2:34 PM. Prior to the resident’s death, there was an incident during a scheduled shower in which the resident, who repeatedly stated she did not want a shower, became combative. CNA F and CNA G reported that the resident was yelling, digging into their skin, hitting, and kicking while being transferred with a mechanical lift and placed on a shower chair. Both CNAs documented that the resident did not want the shower and that she kicked bars in the shower area, resulting in bruising. CNA F stated she was told by RN H that the resident had to receive a shower or she would be written up, and that she held the resident’s arms down by the wrists while CNA G washed the resident. CNA G confirmed that the resident was very irate, kicking, and that she saw CNA F holding the resident’s wrists down while the resident continued to say she did not want the shower, and later stated she considered both the forced shower and the wrist‑holding to be abuse. Clinical documentation and staff statements showed that after the shower incident the resident had bruising, swelling, and an abrasion to the right shin, with swelling from knee to ankle, guarding of the leg, yelling out with touch, and refusal of ROM of the knee. An X‑ray later revealed an acute transverse fibular neck fracture of the lower leg. The DON’s progress note to the guardian indicated that during the shower the resident became aggressive and hit her leg on the shower chair, causing a bruise, and that an X‑ray was ordered. The guardian reported being told that the resident had been hostile during the shower and had kicked a bar on the wall, and that she was later notified of a bruise and then of the resident’s death, without prior calls about a change in condition. Despite CNA F’s written statement and CNA G’s characterization of the incident as abuse, the Administrator stated she was not able to substantiate abuse and therefore did not report the incident to the state agency, resulting in the failure to report suspected abuse as required.
Failure to Investigate Alleged Abuse and Injury During Forced Shower
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an alleged abuse incident and injury involving one resident. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who later expired at the facility. According to staff interviews and documentation, two CNAs attempted to provide a shower using a mechanical lift and shower chair after being directed by an RN that the resident had to receive a shower. The resident repeatedly stated she did not want a shower and became combative, yelling, kicking, hitting, and digging into staff skin. During the shower process, the resident kicked a shower bar on the wall and/or the mechanical lift bar, and staff documented bruising to the right shin and fingertip bruising on the arms from efforts to control the resident’s movements. One CNA admitted to holding the resident’s wrists down while the other CNA washed the resident, and another CNA stated that forcing the resident to shower against her will and holding her wrists down constituted abuse and violated the resident’s rights. Subsequent nursing documentation and a written statement by the RN indicated the resident developed bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, and yelling out with attempts at touch or range of motion. An X-ray later showed an acute transverse fibular neck fracture of the lower leg. The DON documented notifying the resident’s guardian about a bruise to the right shin and indicated the injury occurred when the resident hit her leg on the shower chair during aggression in the shower. Despite the documented injury, staff statements describing actions they considered abusive, and the resident’s expressed refusal of the shower, the facility did not provide an incident report or evidence of a thorough investigation when requested by surveyors. The report states that the facility did not perform an investigation regarding the incident.
Failure to Label and Date Outside Food Stored in Resident Refrigerators
Penalty
Summary
Surveyors found that the facility failed to ensure that food brought in by families and visitors and stored in resident refrigerators was labeled and dated in accordance with facility policy and professional standards. During an observation of the south unit refrigerator with the DON, surveyors observed a large and a small box of outside delivery pizza with no labeling, no date, no expiration date, and no resident name. On another hall, surveyors observed in the refrigerator a bag of tacos from an outside restaurant with a receipt date indicating it had been received several days earlier and was past the facility’s allowed holding time, as well as a salad with no date and no resident name. Additionally, multiple opened 2-liter bottles of soda (blood orange, grape, and another flavor) were present without dates or resident names. The DON acknowledged that these items should have been labeled, dated, and identified with the resident’s name. Review of the facility’s written policy on foods brought in for residents showed that refrigerated cooked food items must be discarded after three days, all opened packages must have an open date and use-by date clearly marked, and foods found without dates are to be discarded, which was not followed in these instances. No specific resident medical histories or conditions were described in the report related to these observations.
Failure to Maintain Proper Positioning of Catheter Drainage Bags
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of indwelling urinary catheter drainage bags for two residents. One resident was observed on multiple occasions lying in bed with a catheter bag that was 100% on the floor and not attached to the bed, despite a care plan intervention dated 9/11/2025 specifying that tubing or any part of the drainage system should not touch the floor. Another resident was repeatedly observed in bed with a catheter bag hanging from the bed but with the bottom of the bag resting on the floor, including after the bag had been moved and attached to a different part of the bed. In interviews, the Infection Control Preventionist stated that catheter bags should always hang on the side of the bed, below the resident and not touching the ground, and the DON confirmed that catheter bags should not be on or hanging on the floor and that this was an infection control concern. These observations and interviews demonstrate that staff did not consistently follow established infection control practices and the resident’s care plan interventions regarding proper positioning of catheter drainage bags, resulting in catheter systems resting on the floor for two of three residents reviewed with catheters.
Failure to Implement Care Plan for Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention to document urinary catheter output for a resident with an indwelling catheter. The resident was admitted with diagnoses including overactive bladder and intellectual disabilities, and a Discharge MDS indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The resident’s catheter/ostomy care plan, dated 10/9/25, included an intervention to document urinary output, yet the output record showed only four entries over a nine-day admission, despite the expectation that catheter output be documented at least once per shift. Nursing documentation later noted that the resident’s catheter was not draining, attempts to flush with sterile water were unsuccessful, and the Foley catheter was removed and replaced, after which 500 mL of dark yellow urine with sediment immediately drained. Interviews confirmed that CNAs were expected to empty catheter bags multiple times per day and document the amount under urine output, and the DON confirmed that urinary catheter output should be documented minimally every shift. The DON acknowledged that the resident had only four documented outputs during the entire admission, demonstrating that the care plan intervention to document catheter output was not consistently implemented.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to assess, monitor, follow physician orders, and document wound care for a resident with non-pressure skin conditions. The resident, a 65-year-old male with diagnoses including hypertension, peripheral vascular disease, wound infection, and diabetes, was admitted with an unstageable wound infected with MRSA. Despite physician orders for daily wound treatments, review of the Medication Administration Record (MAR) revealed over 30 missed treatments without supporting documentation or valid reasons. Weekly wound assessments were also incomplete, with missing documentation on several dates. Interviews with staff confirmed that wound treatments and assessments were not consistently performed or documented as required. Further, the resident reported to wound clinic staff that dressings were not changed daily as ordered, and he often arrived at the clinic with dressings dated more than 24 hours prior. The wound clinic also verified that the resident was not seen for a scheduled appointment on one occasion, contradicting facility staff's belief. The Director of Nursing acknowledged the missed treatments and lack of documentation, and staff interviews confirmed that missed treatments were not always communicated to the physician or documented in progress notes as required by facility policy.
Improper Labeling and Storage of Controlled Medications
Penalty
Summary
Facility staff failed to ensure that controlled medications were properly labeled and stored according to professional standards. A resident, an 84-year-old female with diagnoses including chronic obstructive pulmonary disease, pneumonia, weakness, and depression, was admitted on hospice services and brought Lorazepam 0.5mg tablets from home. Instead of keeping the medication in its original pharmacy packaging, staff repackaged the tablets into nine unlabeled clear plastic bags and a cup, with no resident name, medication name, directions, or description on the packaging. The repackaging was done to facilitate counting at shift change, but staff were unable to identify the tablets by appearance, and the original labeled bottle was empty. Both the RN and DON confirmed the presence of the repackaged, unlabeled controlled medication and were unsure who authorized the repackaging. Interviews with nursing staff revealed that the standard practice was to keep all narcotic medications in their original, clearly labeled pharmacy packaging. However, in this instance, the controlled medication was divided into multiple unlabeled bags, and the staff responsible for this action could not be identified. The facility's documentation showed the medication was received from a home supply and that counts were being performed at shift changes, but the lack of proper labeling and storage did not meet professional standards or regulatory requirements.
Failure to Calibrate Glucometers and Ensure Test Strip Compatibility
Penalty
Summary
The facility failed to ensure that glucometers were calibrated according to manufacturer recommendations and did not ensure compatibility between glucometers and glucose test strips for residents requiring blood glucose monitoring. Observations revealed that calibration logs did not specify the brand of glucometer being calibrated, and several logs had blank columns for control ranges, making it impossible to determine if control results were within acceptable parameters. Multiple types of glucometers and test strips were found on medication carts, with some staff using backup devices and being uncertain about calibration procedures or the frequency of calibration. Interviews with nursing staff, including RNs and LPNs, indicated inconsistent knowledge and practices regarding when and how to calibrate glucometers, particularly when opening new bottles of test strips. Staff often believed calibration was the responsibility of the night or third shift, and some were unsure if calibration was necessary with new test strips. The Director of Nursing also demonstrated uncertainty about calibration requirements and acknowledged that incorrect test strips could result in false blood sugar readings. There was also confusion about which control solutions should be used for calibration, with the DON admitting to using the wrong brand of control solution for a particular glucometer. Documentation showed that at least one control result for a ReliOn Premier BLU glucometer was outside the acceptable range, with no follow-up actions documented. Additionally, calibration logs were missing for some glucometers in use, and there was a lack of clarity about which devices and test strips were being used together. The facility was also found to be out of the correct test strips for certain glucometers, leading to further confusion and improper practices.
Improper Use and Disinfection of Glucometers
Penalty
Summary
The facility failed to follow manufacturer recommendations for the sanitary use and disinfection of glucometers, which potentially affected 17 residents requiring blood glucose monitoring. Observations revealed that staff, including an RN and an LPN, used a ReliOn Premier BLU glucometer for multiple residents, despite the device's user manual specifying it is for single-patient use only and not intended for use in healthcare or LTC settings. Staff reported using Super Sani-Cloth Germicidal Disposable Wipes for cleaning and disinfecting glucometers, although the manufacturer had only validated Clorox Healthcare Bleach Germicidal Wipes for this purpose and warned against using other chemicals. Additionally, the practice of wrapping the glucometer in a disinfecting wipe for two minutes was observed, which contradicted the instructions for both the ReliOn Premier BLU and the Arkray Assure Platinum glucometers. The Director of Nursing was unaware that the ReliOn Premier BLU glucometer was intended for single-patient use only and confirmed that glucometers should not be wrapped in disinfecting wipes unless specified by the manufacturer. The facility's Plan of Correction education record also included a tip to wrap the glucometer in a wipe for the required contact time, which was inconsistent with manufacturer instructions. These actions and inactions resulted in the facility not meeting the requirements for infection prevention and control as outlined in §483.80.
Failure to Document Glucometer Calibration
Penalty
Summary
The facility failed to maintain documentation indicating that glucometer calibration was being performed, potentially affecting all 17 residents diagnosed with diabetes who required blood glucose monitoring. During an interview, an LPN stated that glucometers were quality control tested every 24 hours by the night shift. However, when the glucometer calibration logbook was requested, it could not be found by the Assistant Director of Nursing, the Director of Nursing, or the Regional Nurse, despite searching through various locations including the nurse's station and medication cart. The Regional Nurse confirmed the absence of the logbook and acknowledged that it should be available for monitoring the glucometer's accuracy. The lack of documentation for the glucometer's calibration raised concerns about the potential for inaccurate blood glucose readings and incorrect treatment for diabetic residents. The facility used the Assure Platinum glucometer model, and the manufacturer's manual provides a template for a Quality Control Record, which was not being utilized as required.
Failure to Disinfect Glucometers Between Uses
Penalty
Summary
The facility failed to maintain proper disinfection protocols for glucometers, which are used for blood glucose testing, affecting four residents. During observations, an LPN was seen performing blood glucose tests without disinfecting the glucometer between uses. The LPN placed the glucometer on various surfaces without using a barrier and did not sanitize the device before or after testing. This practice was observed with multiple residents, and the glucometer was not disinfected before being stored back in the medication cart. Interviews with the LPN revealed that while she was aware of the disinfection protocol, she did not consistently follow it due to the unavailability of germicidal wipes. The LPN admitted to not requesting the wipes regularly, citing a hectic work environment as a reason for not obtaining them. The Director of Nursing and a Regional Nurse confirmed that the LPN's actions were incorrect and posed an infection control risk. They also noted that audits to ensure compliance with the disinfection process were not readily available. The facility's records showed that none of the residents tested had a blood-borne pathogen diagnosis, but the lack of proper disinfection still posed a risk of pathogen transmission. The facility used Assure Platinum glucometers, and the manufacturer's guidelines clearly stated the need for cleaning and disinfecting the device after each use. Despite this, the facility's documentation of staff training on glucometer disinfection was incomplete, with only a few competency checklists available for review.
Failure to Prevent Pressure Injuries and Inadequate Pain Management
Penalty
Summary
The facility failed to prevent the development of pressure injuries for a resident who was admitted with a sacral pressure ulcer and later developed additional facility-acquired ulcers. The resident, who had cognitive impairment and multiple medical conditions, was observed lying in bed without proper positioning aids such as pillows to offload pressure or elevate heels. Despite having a care plan that included interventions like repositioning every two hours and using a pressure-reducing mattress, these measures were not consistently implemented. The resident reported severe pain from the ulcers, which hindered his ability to move, and staff did not assist with repositioning or offer pain management effectively. The resident's care plan was not adequately followed, as evidenced by the lack of regular skin assessments and the failure to document any refusals for repositioning. The resident's pressure-reducing air mattress was found unplugged on multiple occasions, and staff did not provide necessary equipment like pillows or wedges to float the resident's heels. Additionally, a medical device-related pressure injury was identified, caused by the wound vac tubing pressing into the resident's skin, further indicating a lack of proper care and monitoring. Pain management was insufficient, as the resident was not offered prescribed pain medication before wound dressing changes, leading to significant discomfort and reluctance to reposition. The staff did not regularly assess the resident's pain levels or offer appropriate pain relief, contributing to the resident's fear of falling and resistance to repositioning. The facility's failure to adhere to the care plan and manage the resident's pain effectively resulted in the development of additional pressure injuries and significant distress for the resident.
Inadequate Pain Management for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R26, who was admitted with multiple serious medical conditions including sepsis, osteomyelitis, and a Stage 4 sacral pressure ulcer. The resident also developed additional pressure ulcers after admission. Despite having a care plan that included administering pain medication as ordered, the facility did not consistently provide the prescribed pain relief, particularly before wound care procedures, which resulted in the resident experiencing severe pain. R26's medical records indicated an order for Oxycodone to be administered as needed and before dressing changes, but this was not consistently followed. The resident reported severe pain during wound care, rating it as high as 9 or 10, and expressed that the pain was excruciating, preventing him from wanting to be moved in bed. Despite the presence of a physician's order for pain management, the medication was only sporadically administered, and the resident was unaware of the availability of stronger pain relief options beyond Tylenol. Interviews with nursing staff confirmed that R26 often refused wound care and repositioning due to pain, and it was verified that no as-needed pain medication was administered prior to dressing changes. The inconsistency in pain assessments and the lack of regular pain medication offerings contributed to the resident's ongoing pain and anxiety, highlighting a significant deficiency in the facility's pain management practices.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to ensure that notifications of emergency transfers for 41 residents were sent to the State Long-Term Care Ombudsman over the past year. During an interview, the Ombudsman confirmed that she had not received any notifications of resident emergency transfers and had inquired about them several times without receiving a response or copies. The Regional Clinical Director (RCD) was unable to provide evidence that the notifications were sent, despite being requested to do so. A list of residents who were emergency transfers was provided, but no documentation proving that the notifications were sent to the Ombudsman was available.
Deficiencies in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 49 residents. During an initial tour of the food service area, several deficiencies were observed, including peeling packing shrink wrap on the doors of two coolers, and various kitchen appliances such as a can opener, microwave oven, stand mixer, stove/oven/griddle, and garbage disposal were found with accumulated and encrusted food residue. Additionally, the broom waste caddies and dry storage room light assembly were heavily soiled with dust, dirt, and dead insect carcasses. The mechanical dish machine ventilation hood was also observed with corroded moisture stains and grime. Further inspection revealed that the three-compartment sink waste lines were heavily soiled and direct plumbed without an effective air gap, violating the 2017 FDA Model Food Code. The facility's kitchenettes also exhibited similar issues, with soiled ventilation grills and light assembly covers containing dead insect carcasses and dust. These observations indicate a failure to adhere to professional standards for food safety and sanitation, increasing the risk of cross-contamination and bacterial harborage. Record reviews of the facility's policies and procedures showed that there were established guidelines for cleaning and sanitizing equipment such as hoods, filters, ranges, ovens, and grills. However, the observed conditions suggest that these policies were not effectively implemented or followed, leading to the noted deficiencies in maintaining a clean and safe food service environment.
Improper Maintenance of Outdoor Waste Receptacle
Penalty
Summary
The facility failed to effectively maintain the outdoor waste receptacle, impacting 49 residents. During an environmental tour, it was observed that the outdoor waste receptacle was missing the rear sliding door and had one of its two swinging doors cracked and broken. This condition increased the likelihood of pest attraction and harborage. The Dietary Manager acknowledged the issue and indicated plans to contact the waste removal company for necessary repairs. A review of the facility's policy and procedure on sanitizing garbage cans and dumpsters revealed that garbage cans should be thoroughly cleaned and sanitized regularly, and any damage to the containers should be reported to the Dietary Manager for replacement. Additionally, dumpsters provided by the local refuge vendor should be maintained by the facility and kept covered at all times, with the area around the dumpster kept clean and free of debris, foul odors, and pests.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting 49 residents, as observed during an environmental tour. The laundry service area was found with heavily soiled flooring and light covers with dead insect carcasses. In the common areas, missing atmospheric vacuum breakers, damaged chairs, and soiled ventilation grills were noted. Additionally, the dining room had tables with missing leg support levelers and light bulbs secured with zip ties. In the resident rooms, several deficiencies were observed, including soiled flooring, stained ceiling tiles, and non-functional light bulbs. Restrooms were found with etched and stained caulking, malodorous conditions, and missing toilet tissue. Some rooms had damaged drywall and frayed electrical wires, posing potential safety hazards. The maintenance request logs did not reflect these issues, indicating a lack of proper documentation and follow-up. The facility's policies and procedures for housekeeping and maintenance were reviewed, revealing a lack of specific dates and inadequate monitoring for compliance. The policies stated the importance of maintaining a safe and sanitary environment, but the observed conditions contradicted these guidelines. The failure to adhere to these policies resulted in an increased likelihood of cross-contamination and decreased air quality, compromising the residents' living conditions.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food products, affecting 49 residents. Observations revealed that food trays were delivered from the kitchen in insulated transport carts, but the food temperatures did not meet the standards set by the 2017 FDA Model Food Code. For instance, the corn served to Resident #1 was recorded at 126.2°F, and the milk was at 49.7°F, both outside the safe temperature range. Additionally, the food was described as unappetizing, with the beef burrito being semi-tough and dry, and the Spanish rice starchy and dry. Interviews with residents highlighted dissatisfaction with the food quality and lack of alternative meal options. Resident #22 reported not eating any food since admission, and Resident #26 mentioned refusing meals due to poor taste. Residents expressed that the only alternative offered was a peanut butter and jelly sandwich, and there was no discussion of their food preferences. The absence of an alternative menu was confirmed during observations, and residents expressed frustration over the lack of variety and the facility's unfulfilled promises to implement an alternative menu. The dietary staff, including the Dietary Manager, acknowledged the issues with the meal service. The Dietary Manager indicated that an alternate meal choice was assigned only for the main entree and mentioned plans to implement an always-available menu option. However, at the time of the survey, no such menu was in place, and the food delivery schedule contributed to the temperature issues, as trays were delivered to different dining rooms sequentially, potentially affecting the food's temperature and palatability.
Deficiency in Wheelchair Maintenance and Infection Control
Penalty
Summary
The facility failed to ensure safe and clean medical equipment for a resident, specifically regarding the condition of a wheelchair. The resident, who has severe cognitive impairment and multiple medical conditions including Alzheimer's Disease and dysphagia, was observed on two separate occasions sitting in a wheelchair with a torn and cracked right arm cushion. This condition was noted during observations in the common area of the unit, and the resident was unable to participate in an interview due to their cognitive impairment. The Licensed Practical Nurse (LPN) responsible for the resident acknowledged the issue upon observation but had not reported it to the Assistant Director of Nursing (ADON) as required. The LPN confirmed that the damaged cushion posed an infection control issue because it could not be adequately cleaned. The ADON also confirmed that no staff had reported the need for repair of the wheelchair, indicating a lapse in communication and protocol adherence within the facility.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident #33, regarding the use of restraints. The resident was admitted with multiple diagnoses, including cerebral infarction, hemiparesis, hemiplegia, aphasia, and other conditions. During an observation, the resident was seen using side rails on the bed for positioning and assistance with getting up. However, the MDS assessment inaccurately coded these side rails as restraints, despite the facility's policy that side rails used for assistance and not restricting movement should be considered assistive devices. Interviews with the Assistant Director of Nursing (ADON) and the MDS Coordinator revealed discrepancies in the coding of the MDS. The ADON confirmed that the side rails were not considered restraints and that the facility did not measure these devices to prevent potential entrapment. The MDS Coordinator admitted to mistakenly coding the side rails as restraints and acknowledged the need to correct and resubmit the MDS. This error highlights a failure in accurately assessing and documenting the resident's use of assistive devices, leading to an incorrect MDS assessment.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete and provide a baseline care plan within 48 hours of admission for a resident, identified as Resident #22. The resident was admitted with multiple complex medical conditions, including iron deficiency anemia, end-stage renal disease, and severe protein-calorie malnutrition, among others. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident was unaware of any details regarding her plan of care and denied receiving a copy of the baseline care plan within the required timeframe. Interviews with facility staff revealed that the baseline care plan was completed but not uploaded into the resident's medical record until after the surveyor's inquiry. The Assistant Director of Nursing and the Regional Clinical Director acknowledged the oversight, with the latter noting that the second page of the care plan, which would have shown the resident's review and agreement, was incomplete. The facility's policy mandates the completion and implementation of a baseline care plan within 48 hours to ensure continuity of care and communication, which was not adhered to in this case.
Failure to Apply Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with multiple contractures received appropriate care to maintain or improve their range of motion. The resident, who had contractures in both upper and lower extremities, was observed multiple times without the necessary splints and braces that were supposed to be applied daily. Despite instructions posted in the resident's room and outlined in the care plan, the splints were consistently found on a chair rather than on the resident. This lack of adherence to the care plan potentially contributed to the worsening of the resident's contractures. Interviews with staff revealed inconsistencies in the understanding and execution of the resident's care plan. Certified Nurse Aides (CNAs) provided conflicting information regarding who was responsible for applying the splints, with some stating that therapy staff applied them, while others indicated it was the CNAs' responsibility. Additionally, CNAs reported not having access to printed care plans, relying instead on computer access to review care instructions, which may have contributed to the oversight. The Physical Therapist Assistant confirmed that the resident was supposed to have knee splints applied daily, further highlighting the discrepancy in care delivery.
Failure to Obtain Resident Weights and Address Nutritional Preferences
Penalty
Summary
The facility failed to adhere to its policy of obtaining weights for a resident, leading to potential inaccuracies in assessing the resident's nutritional status. Resident #26, who was admitted and later readmitted with multiple diagnoses including sepsis, osteomyelitis, a sacral pressure ulcer, muscle weakness, and type 2 diabetes, was not weighed weekly for four weeks following admission as required. The resident's medical record showed an admission weight of 240 lbs, a readmission weight of 259 lbs, and a subsequent weight of 210.3 lbs, indicating a significant weight loss of 48.7 lbs (18%) over 28 days. There were no documented refusals for the missed weights, and the Registered Nurse confirmed the absence of documentation for the weekly weights. Additionally, the resident expressed dissatisfaction with the facility's food, often refusing meals, which may have contributed to the weight loss. The resident reported that no one had discussed his food preferences with him, and his menu ticket lacked information on his likes and dislikes. The Registered Dietician noted the weight loss and requested a reweigh to verify accuracy, but it had not been completed by the time of the report. The failure to document weights and address the resident's nutritional preferences contributed to the deficiency identified by the surveyors.
Improper Storage and Cleaning of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for two residents, leading to potential cross-contamination and respiratory illnesses. Resident #18, a cognitively intact female with multiple health conditions including chronic lung disease and heart failure, was observed with undated oxygen tubing and unbagged nebulizer equipment. Her CPAP mask was found lying on her pillow, and the oxygen tubing was dated over two weeks prior to the observation. The resident had been diagnosed with facility-acquired pneumonia in July 2024, and her physician orders required the use of CPAP during sleep and oxygen therapy for comfort or low oxygen saturation levels. Resident #37, also a cognitively intact female with similar health conditions, was observed with her oxygen concentrator running and the nasal cannula lying directly on bed linens. Additionally, her nebulizer equipment was found on the cushion of her wheelchair. The Assistant Director of Nursing/Infection Control Nurse stated that oxygen tubing should be changed every seven days and nebulizer equipment should be rinsed and stored in a bag after use. These observations indicate a failure in maintaining proper infection control practices for respiratory equipment, increasing the risk of cross-contamination and respiratory complications.
Failure in Dialysis Communication and Weight Tracking
Penalty
Summary
The facility failed to ensure effective communication and collaboration with the contracted dialysis facility for a resident requiring dialysis care, leading to issues in tracking the resident's weight. The resident, who has end-stage renal disease and a binge eating disorder, was admitted and readmitted to the facility with an active physician's order for weekly weight monitoring. However, the medical record showed inconsistencies in weight documentation, with significant gaps between recorded weights and no documented refusals for the weekly weights. The Dialysis Communication Binder, which should have contained completed forms from the dialysis facility, was found to have several incomplete forms. These forms were meant to document vital information, including pre- and post-dialysis weights. An RN at the facility acknowledged that the resident had an order for weekly weights but stated that the resident was refusing to be weighed at the facility, leading to an agreement to use weights obtained at the dialysis center. However, the dialysis facility did not consistently complete and return the necessary communication forms, contributing to the deficiency in tracking the resident's weight as per the physician's order.
Failure to Assess and Measure Bed Rails for Entrapment Risk
Penalty
Summary
The facility failed to ensure that bed rails were properly assessed and measured to prevent possible entrapment for a resident using bed rails. The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiparesis, hemiplegia, and moderate cognitive impairment, was observed using side rails for positioning and assistance with bed mobility. Despite the resident's medical record indicating the use of bed rails and a trapeze to promote independence, the facility did not complete the necessary measurements of the side rails to prevent potential entrapment. Interviews with facility staff revealed that the Assistant Director of Nursing acknowledged the use of side rails but admitted that the facility did not measure these devices to prevent entrapment. The Regional Clinical Director and Nurse confirmed that bed rail assessments with measurements were supposed to be completed at installation and quarterly, but no such measurements for the resident could be found. The facility's policy required maintenance staff to install bed rails according to manufacturer's recommendations and to initiate a bed rail assessment prior to installation, but these procedures were not followed for the resident in question.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. During an observation, a Registered Nurse (RN) administered a Hyoscyamine 0.25 mg tablet to a resident by mixing it with pudding, despite the medication being ordered for sublingual administration. This error was observed as the resident swallowed the medication instead of allowing it to dissolve under the tongue as prescribed. Another RN was observed administering Flomax to a resident before breakfast, contrary to the order specifying it should be given after breakfast. Additionally, the RN did not ensure the resident swallowed the medication, resulting in pills falling to the floor. The same RN also failed to prime an insulin pen before administering insulin, which is against the facility's policy. The RN attributed this oversight to being a travel nurse and unfamiliar with the facility's procedures.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medications and treatment carts were secured, as observed during a survey. On multiple occasions, two treatment carts located in the resident's dining room were found unlocked, with drawers open revealing wound treatment supplies and prescribed topical medications. This was observed on two consecutive days, with the carts remaining unsecured at various times, indicating a lack of adherence to protocols for securing medication and treatment supplies. Additionally, during a medication administration observation, a registered nurse was seen leaving a medication cart unlocked and a computer open with a resident's medical record exposed. This occurred while the nurse administered medications to a resident in the dining area, with the cart only partially in view and the nurse's back turned towards it. These actions demonstrate a failure to maintain the security of medications and the confidentiality of resident records.
Failure to Provide Alternative Food Choices
Penalty
Summary
The facility failed to provide alternative food choices for three residents, leading to dissatisfaction and a non-pleasurable dining experience. Resident #26 expressed dissatisfaction with the taste of the food and reported that he often refused meals, with only a peanut butter and jelly sandwich available as an alternative. He also mentioned that no one had discussed his food preferences with him. Resident #41 also found the food unappealing and was only aware of the option to make a peanut butter and jelly sandwich if she did not like the meal provided. Resident #13 described the food as gross and noted that there was no alternative menu available, despite promises from the facility to create one. Observations during meal times revealed that the food served was not appetizing, with specific mention of a lunch consisting of a beef burrito, Spanish rice, and corn, which did not appear appealing. The Spanish rice was served in a scoop form, and a taste test by the surveyor found the spaghetti sauce to be overly salty and the meatballs unappetizing. The Dietary Manager acknowledged the lack of an alternative menu and stated that the current practice was to substitute only the main entree with an alternate choice, with plans to implement an always-available menu option in the future.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in the potential for inadequate care and lack of information regarding hospice services. The resident, who was admitted with multiple diagnoses including COPD and dementia, was receiving hospice care but was not provided with a hospice calendar detailing the schedule of services. During an interview, the resident was unable to specify when hospice services were provided, indicating a lack of communication and coordination. Further investigation revealed that the facility's hospice notebook, which should have contained a calendar of hospice services and a plan of care, was incomplete. The Assistant Director of Nursing could not provide documentation of the hospice plan of care or a comprehensive calendar of visits. Additionally, the Social Worker confirmed that a care conference with the hospice agency had occurred but had not been documented in the resident's medical record in a timely manner, highlighting a delay in the coordination of hospice services.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter, which is an infection control intervention aimed at reducing the transmission of multidrug-resistant organisms. The resident, who was admitted with multiple diagnoses including a urinary tract infection, was observed to have a sign on their room door indicating the need for EBP, which requires staff to wear gloves and gowns during high-contact care activities. Despite this, observations revealed that a Licensed Practical Nurse (LPN) and a Certified Nursing Aide (CNA) did not wear isolation gowns while performing tasks such as dressing changes and emptying the urinary collection bag. The Director of Nursing (DON) confirmed that the resident was on EBP due to the presence of a suprapubic catheter and acknowledged that the staff should have been wearing gowns in addition to gloves during these procedures. The DON was aware of the non-compliance with EBP protocols during the surveyor's observation and identified that the necessary precautions were not followed by the staff involved.
Failure to Protect Resident from Abuse During Medical Procedure
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving a straight catheterization procedure. During the procedure, the resident was left exposed with her legs open, and the room curtain and door were left open, exposing her private area to anyone outside the room. The resident reported feeling humiliated, vulnerable, upset, scared, and threatened. Additionally, a registered nurse (RN) made inappropriate comments to the resident, suggesting she should have stayed home and had home care, and threatened to send her to the emergency room if she did not allow the use of her personal catheterization supplies. The RN also went through the resident's personal belongings without permission in search of a straight catheter kit. The facility's administrator confirmed that the RN had previously been verbally abusive to the resident and had refused to perform the necessary catheterization procedure. The RN was terminated from employment due to these actions. An employee memorandum revealed that the RN, acting as the charge nurse, had directed subordinates not to provide care to the resident, leading to the RN's discharge from the facility.
Failure to Develop Comprehensive Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to develop a comprehensive pressure ulcer care plan for two residents. Resident #1, who was admitted with a right above-the-knee amputation and paraplegia, had a pressure ulcer on his left heel that was not documented in his care plan. Despite discharge instructions from a vascular surgeon for wound care, the resident reported that no staff member had performed dressing changes, and he had been managing the wound himself. The wound care nurse did not follow up on the surgeon's orders or assess the wound, leading to a lack of proper documentation and care planning for the pressure ulcer. Resident #2, admitted with quadriplegia, had a pressure ulcer on her right buttocks that was not included in her care plan. Despite the resident informing staff about the wound, it was not documented in her skin assessments or care plan. The Director of Nursing stated that it was the facility's policy for CNAs to perform skin sweeps during showers and report any concerns, but this procedure was not followed. The lack of proper skin assessments and documentation resulted in the resident's pressure ulcer not being addressed in her care plan.
Failure to Document Lab Orders and Maintain Infection Control
Penalty
Summary
The facility failed to write a physician order for a laboratory test and document a resident assessment, rationale for the lab test, and completion of the lab draw procedure for Resident #4. The resident, who was admitted with multiple severe diagnoses including stage 4 pressure ulcer and quadriplegia, experienced a change in condition that prompted the Director of Nursing (DON) to draw blood based on a verbal order from the physician. However, the DON did not document the order in the electronic medical record (EMR) nor complete a progress note to reflect the resident's status, physician coordination, or the blood draw procedure. This lack of documentation was confirmed by the DON during an interview, and it was noted that the facility's policy required such documentation for any change in resident condition and lab tests ordered and performed by staff. The facility's policy on nursing practices and laboratory tests was not followed in this instance, leading to the deficiency cited by the surveyors. The facility also failed to administer medications as ordered by the physician and maintain infection control prevention during catheterization for Resident #2. The resident, who was diagnosed with quadriplegia, was supposed to receive specific medications at designated times, but there was a discrepancy in the administration of Baclofen and Vesicare. During an interview, the Assistant Director of Nursing (ADON) discovered that the morning nurse had not documented the administration of Baclofen, leading to confusion about whether the medication had been given. Additionally, the ADON initially provided an incorrect dosage of Vesicare, which was corrected after the resident pointed out the error. This failure to properly administer medications as ordered was a significant deficiency. Furthermore, during an observation of a straight catheterization procedure for Resident #2, the Registered Nurse (RN) failed to follow proper infection control practices. The RN did not wash or sanitize her hands between glove changes and before opening the sterile catheter kit, which is against the facility's policy and procedure. The Director of Nursing (DON) confirmed that the RN should have washed her hands after assisting the resident with toileting and before proceeding with the catheterization. This failure to maintain infection control during a medical procedure was another critical deficiency identified by the surveyors.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for three residents, leading to deficiencies in care. Resident #1, who was admitted with a pressure ulcer on his left heel, did not receive the prescribed wound care. Despite having orders from a vascular physician, the facility did not document or implement these orders. The resident had to perform his own dressing changes due to the lack of staff intervention, and the wound was not included in his skin assessments or care plans. The wound care nurse did not follow up on the necessary treatments, and the nurse practitioner was not informed of the wound until much later, resulting in inadequate care and documentation for the resident's pressure ulcer. Resident #2, admitted with quadriplegia, had a pressure ulcer on her right buttocks that was not documented in her skin assessments or care plans. The resident reported the wound to the Director of Nursing and a registered nurse, but no treatment orders were written until much later. The resident did not receive a full skin assessment, and the nurse practitioner was not made aware of the wound until the resident personally informed her. This lack of communication and documentation led to a delay in appropriate wound care for the resident. Resident #4, admitted with multiple pressure ulcers and severe cognitive impairment, did not receive consistent and appropriate wound care. The resident's wounds were not cleansed with the correct solutions as per the physician's orders, and the strength of the Dakins solution used was not specified. The resident's sacral wound dressing was found to be missing, and the staff was unaware of this issue. The registered nurse used sterile water instead of normal saline for wound cleansing, and the Director of Nursing confirmed that the facility did not stock the correct strength of Dakins solution. This resulted in improper wound care and inadequate monitoring of the resident's condition.
Latest citations in Michigan
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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