Mission Point Nsg Phy Rehab Ctr Of Madison Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison Heights, Michigan.
- Location
- 31155 Dequindre, Madison Heights, Michigan 48071
- CMS Provider Number
- 235187
- Inspections on file
- 32
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission Point Nsg Phy Rehab Ctr Of Madison Heights during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including a history of falls, experienced a fall due to inadequate supervision and incorrect care plan documentation. The facility failed to update the care plan and CNA Kardex to reflect the need for a two-person assist for bed mobility, despite a decision made by the interdisciplinary team. This discrepancy led to a potential risk for additional falls.
The facility's ice machines in the main kitchen and on the first floor were found to lack backflow protection, as their drain lines extended into the floor drains without an air gap. This deficiency was observed and confirmed through interviews, with the Dietary Manager unaware of the requirement. The lack of backflow prevention posed a potential risk to all residents.
The facility failed to maintain light cords at an appropriate length within reach for five residents on the 2 East unit. Observations showed that the light pull strings were too short, making them inaccessible. Staff were unaware of the issue, and no documentation of repairs was provided.
The facility failed to maintain a safe, clean, and homelike environment, affecting multiple residents. Observations revealed foul odors, mold, and maintenance issues in shower rooms, as well as debris and cleanliness problems in residents' rooms. Staff confirmed these issues, and documentation for maintenance was lacking. Facility policies on cleaning and resident rights were not followed, leading to these deficiencies.
The facility failed to properly store and label medications in two medication carts. An insulin pen was found without a label, and another was mislabeled with a future date. Additionally, an antidepressant was stored in the wrong cart and left unsecured. The DON confirmed the protocol for labeling and storing medications.
An LPN failed to follow infection control protocols during medication administration by not cleaning equipment and neglecting hand hygiene between residents. Additionally, a CNA improperly placed a meal tray on their lap while assisting a resident, contrary to hygienic dining practices. These actions were against the facility's policies.
The facility failed to maintain adequate ventilation in the 2 East Shower Room, resulting in stale and malodorous air affecting all residents using the room. Observations confirmed non-functioning ventilation, and the Plant Operations Manager acknowledged the issue without providing an explanation for the lack of monitoring. Maintenance logs showed no documented concerns, and the facility did not provide a policy on bathroom ventilation or relevant repair invoices.
The facility failed to maintain residents' rights to receive unopened and private mail. Two residents reported issues: one received opened Christmas cards, and another experienced delays and was told to open packages in front of staff, violating their privacy. The Administrator was unaware of these practices, which contradicted facility policies on mail privacy.
The facility failed to educate and offer a resident the opportunity to formulate an advance directive, as required by policy. The resident, admitted with bipolar disorder and depression, had no documentation of being offered this option. Interviews revealed confusion about departmental responsibilities, with the Social Services Manager stating they only handled code status, not advance directives. The Acting Administrator later confirmed the social services department's responsibility, but no further documentation was provided.
A resident with severe cognitive impairment was found with a bruise around their eye, initially attributed to lying on a bed remote. Despite worsening bruising and swelling, the facility did not report the injury as unknown in origin to the state agency, believing they knew the cause. Staff interviews revealed the resident's condition was assessed, but the facility assumed the injury's origin and did not report it.
A resident with mental health diagnoses did not receive a required PASARR Level II Evaluation by the specified deadline. The facility's Social Services Manager confirmed the evaluation was neither completed nor submitted, despite policy requirements for tracking PASARR screening status.
An LPN failed to ensure proper medication administration for two residents. The LPN did not observe one resident consuming their medications and left another resident's pills unattended. The facility's policy requires observation to ensure ingestion, which was not followed. The DON confirmed the LPN's actions were inconsistent with protocol.
A facility failed to accurately account for a resident's controlled medication, Hydrocodone-Acetaminophen, due to improper documentation and protocol adherence. An LPN reported administering one pill and discarding another without documenting the wastage on the proof-of-use form. Although a second LPN witnessed the wastage, neither signed the form as required by facility protocol. The Director of Nursing confirmed the protocol, but a policy was not provided during the survey.
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. A resident with a history of violent behavior punched another resident over a disagreement, and another resident with severely impaired cognition assaulted two different residents on separate occasions. Despite these incidents being witnessed and reported, the facility delayed implementing appropriate care plans to prevent further harm.
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse, involving residents with impaired cognition and aggressive behavior. Key witnesses and involved parties were not interviewed, and documentation was insufficient, leading to a lack of understanding of the root causes and potential for further abuse.
A resident with severely impaired cognition and a history of elopement risk exited a facility unnoticed and walked to a police station. Despite being identified as an elopement risk, the facility failed to implement effective interventions or provide adequate supervision. Staff interviews revealed a lack of communication and awareness regarding the resident's elopement risk and necessary interventions.
A resident experienced a 13.5% weight loss over several months due to the facility's failure to monitor and address nutritional needs. Despite being dependent on staff and having severe cognitive impairment, the resident's weight was not documented in March, and significant weight loss was not addressed until May. The registered dietician was unaware of the weight loss due to missed alerts, and the facility's weight monitoring policy was not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions such as pressure ulcers and indwelling devices, as required. Observations showed a lack of EBP signage and PPE availability in residents' rooms. Staff interviews revealed insufficient training and awareness of EBP protocols, contributing to the deficiency. During a dressing change for a resident with a pressure ulcer, an LPN did not use the required PPE, further highlighting the facility's failure in infection control measures.
The facility failed to ensure a safe environment by leaving emergency carts unlocked with sharp objects accessible, including razors and suture kits. A resident was observed accessing one of these carts and removing emergency equipment, highlighting inadequate supervision and increased accident risk. The DON and an LPN acknowledged the issue.
The facility failed to maintain an effective antibiotic stewardship program in May 2024, with incomplete documentation and lack of infection control measures. The DON, who started at the end of May, found the program disorganized and began revamping it. The Administrator confirmed the issue, noting a past non-compliance finding.
The facility failed to respect the dignity and preferences of two residents. One resident, who is cognitively intact, felt forced to take a shower despite preferring bed baths, and had to use an unsuitable wheelchair due to the lack of an appropriate shower chair. Another resident, who is blind, reported that some CNAs argued or refused to provide showers, and they could not identify the CNAs due to their blindness and lack of name disclosure. The facility's policy on maintaining resident dignity was not followed.
A facility failed to report an abuse allegation when a resident threatened another with a fork. The incident was reported to staff, including a Social Worker, but not documented or reported to the Abuse Coordinator and State Agency. The resident who reported the threat was cognitively intact, while the resident who made the threat had schizophrenia and was later sent for psychiatric evaluation. Despite awareness by the Social Worker, the Administrator was not informed, violating the facility's abuse reporting policy.
A resident with a history of falls was not provided with a concave mattress or floor mats as indicated in their care plan. Despite a physician's order, these interventions were absent during observations. The resident, with severe cognitive impairment and dependent on staff, had a care plan that was not updated to reflect changes in their fall risk status, leading to a deficiency.
A resident with multiple diagnoses, including diabetes and atrial fibrillation, refused medications during an observed administration. However, an LPN erroneously documented the medications as given in the MAR. The LPN later confirmed the error, attributing it to nervousness during the observation. The DON was informed of the documentation mistake.
The facility failed to ensure shaving per personal preference for two residents who required assistance with ADLs. One resident, who is blind, reported CNAs refused to shave him, while another resident with impaired cognition was observed with a full beard despite preferring to be clean-shaven. Both residents were later observed clean-shaven after receiving assistance. Interviews revealed residents are usually shaved during showers or upon request, as per facility policy.
A facility failed to monitor blood glucose levels for a diabetic resident after readmission, despite previous unstable levels and sliding scale insulin use. The resident, with multiple health issues, was not monitored for 12 days, leading to a cardiac arrest and death. Interviews revealed a lack of clarity and documentation regarding monitoring decisions.
A resident developed an avoidable unstageable pressure ulcer due to the facility's failure to provide an appropriate support surface bed. Despite the resident's repeated complaints about the bed's inadequacy, no corrective action was taken. The resident's pressure ulcer was not present upon admission and was observed to be a Stage III ulcer with moderate drainage. Dressing change orders were inconsistently followed, and the facility's maintenance records did not document any requests regarding the bed issue. The facility's policy on pressure injury prevention was not effectively implemented.
A resident with significant cognitive impairment and multiple diagnoses, including stroke and muscle weakness, was observed without prescribed braces or palm protectors to maintain range of motion. Despite care plan orders, staff failed to apply these interventions consistently, as confirmed by multiple observations and staff interviews. The facility's policy required systematic assessment and care planning, which was not effectively executed, leading to potential further decline in the resident's condition.
A resident with PTSD, stroke-induced paralysis, and schizophrenia did not receive a trauma-informed care assessment or care plan upon admission to the facility. Despite the facility's policy requiring such assessments, the Social Work Director confirmed that the assessment was not completed, resulting in a lack of interventions to address potential PTSD triggers.
A facility failed to document a physician's response to pharmacy recommendations for a resident with dementia, breast cancer, and anorexia. The resident's MRR dated February 2024 lacked a report or response in the electronic record. The new DON could not locate the report or identify the concern, and the facility did not provide an MRR policy by the survey's end.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.9%. An LPN documented administering Eliquis and Ferrous Sulfate to a resident who refused the medications, leading to a discrepancy in the MAR. The DON was informed of the error, which violated the facility's medication administration policy.
The facility failed to provide timely laboratory services for two residents receiving Depakote, as ordered by their physicians. One resident required valproic acid level monitoring, but no results were found in their clinical record despite a pharmacy recommendation and physician's order. Another resident's lab tests were delayed by a month, with results showing low valproic acid levels. The facility's policy requires timely provision of laboratory services, which was not met in these instances.
The facility failed to maintain a clean, comfortable, and homelike environment, with offensive odors, overflowing garbage, soiled floors, and broken equipment. Housekeepers reported being short-staffed, leading to significant cleanliness issues. The facility lacked documentation for work orders, cleaning schedules, and policies for storage and cleaning.
The facility failed to provide necessary monitoring, supervision, and interventions for a resident with a known alcohol addiction. Despite multiple instances of the resident leaving and returning intoxicated, no care plans or interventions were implemented. Staff acknowledged the lack of formal care plans and interventions, leading to the cited deficiency.
The facility failed to protect two residents from physical abuse by another resident and did not adequately address a staff member's misappropriation of funds from a resident. The incidents were substantiated as abuse after investigations, revealing significant deficiencies in ensuring a safe environment.
The facility failed to report a suspected abuse incident involving two residents within the required 24-hour window. The incident, which involved verbal sexual requests, occurred in January but was not reported until February. Both residents were interviewed, and the delay in reporting was confirmed by the RN Regional Clinical Director.
The facility failed to thoroughly investigate allegations of stolen money from one resident and verbal abuse by a staff member towards another resident. The DON was unaware of the incidents until days later and did not conduct a thorough investigation. Additionally, the facility did not address the theft of $75 from another resident, and staff were unclear about where to store personal items, leading to potential security issues.
The facility failed to follow its policies for Leave Of Absence (LOA) and Against Medical Advice (AMA) discharge for a resident. The resident left the facility without a physician's order or proper documentation, and the DON and SSM did not follow procedures for educating the resident or notifying the physician. This resulted in inadequate documentation and communication regarding the resident's status.
The facility failed to revise the care plan for a resident who exhibited aggressive behavior towards another resident. Despite the incident being documented and witnessed by a CNA, no interventions were added to the care plan to prevent further mistreatment, and there was no documentation of the interdisciplinary team meeting to discuss the behavior.
The facility failed to provide necessary behavioral health care for a resident with alcohol dependence, allowing the resident to leave unsupervised and return intoxicated multiple times. Interviews revealed a lack of internal planning and coordinated efforts to manage the resident's condition, resulting in ongoing substance abuse issues.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement appropriate interventions and update the care guides for a resident, R602, after a fall, which resulted in the potential for additional falls. R602 was observed in bed with a fall mat on the right side, and their clinical record indicated multiple diagnoses, including cerebrovascular disease, flaccid hemiplegia, and a history of falls. On a specific date, a nurse noted that an aide had lowered R602 to the floor after being unable to hold them during a brief change. The aide was alone and believed R602 required only a one-person assist for bed mobility, as indicated in the CNA Kardex. Interviews with staff revealed inconsistencies in the care plan and CNA Kardex regarding the level of assistance required for R602's bed mobility. While the interdisciplinary team had decided to change R602's status to a two-person assist for all activities of daily living (ADLs) after the fall, the care plan and CNA Kardex still documented a one-person assist for bed mobility. The Assistant Director of Nursing acknowledged the discrepancy and agreed that the documentation should have been updated to reflect the change. The facility's Fall Reduction Policy requires that care plans be reviewed and updated after a fall, which was not adequately done in this case.
Ice Machines Lack Backflow Protection
Penalty
Summary
The facility failed to ensure that the ice machines in the main kitchen and on the first floor were backflow protected, which is a requirement to prevent contamination. During an observation on January 7, 2025, it was noted that the drain lines of both ice machines extended approximately 2 inches into the floor drains, lacking the necessary air gap to prevent backflow. This deficiency was confirmed through interviews and record reviews, with the Dietary Manager acknowledging the issue but being unsure about the air gap requirement. The lack of backflow prevention was identified as a potential risk to all residents in the facility, as it could lead to contamination of the ice used by residents.
Inaccessible Light Cords for Residents
Penalty
Summary
The facility failed to ensure that light cords were maintained at an appropriate length and within reach for five residents on the 2 East unit. Observations conducted over two days revealed that the rooms occupied by these residents had lights above their beds with metal pull strings that were only a few inches long, making them inaccessible for use. During a walkthrough with the Plant Operations Manager/Maintenance Director and the Housekeeping/Laundry Supervisor, it was noted that the issue had not been identified in any audits or maintenance logs. Staff reported that many residents on the unit had behaviors of pulling things off the walls, including light cords, but there was no specific awareness of the issue in these rooms. The facility was unable to provide any documentation of furniture, room, or equipment repairs related to this issue by the end of the survey.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, affecting multiple residents throughout the facility. Observations on the 2 East unit revealed stagnant, strong foul odors in the shower room, a build-up of dark brownish substance along the shower walls and flooring, chipped and missing tiles, and a sharp metal area on the handrail. The 1 East shower room had heavy mold/mildew accumulation, a dust-coated ceiling vent cover, and water-stained ceiling tiles. A brown soiled towel was left on the floor in a resident's bathroom, and an overbed tray table used by multiple residents was caked with debris and had a damaged surface. Several residents' rooms were observed with various cleanliness and maintenance issues. One room had a wall with missing paint, a broken soap dispenser, and no available soap. Another resident's overbed tray table was heavily soiled, and the room's flooring was scattered with debris. Privacy curtains were soiled, and bedside dressers were heavily worn and broken. Debris was scattered in another resident's room, and the resident reported that housekeeping had not cleaned the room for several days. A shared room had trash and debris throughout, used gloves scattered around beds, and a trash can without a bag. The facility's staff, including the Plant Operations Manager and Housekeeping/Laundry Supervisor, confirmed many of these observations. They acknowledged that the showers should be cleaned daily and that the sharp metal handrail should have been reported. The maintenance binder lacked documentation of issues with overbed tray tables, and there was no further documentation provided for furniture or equipment repairs. The facility's policies on cleaning and resident rights emphasize the importance of maintaining a safe and clean environment, but these were not adhered to, leading to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in two of the three medication carts reviewed. During an observation of the 1 Central Unit medication cart, a Novolog insulin pen was found without a label indicating the resident's name or the date it was opened. LPN 'B' acknowledged the oversight, stating that the pen should have been labeled with both the resident's name and the date it was opened. Additionally, a Lantus insulin pen was incorrectly labeled with a future date, and LPN 'B' was uncertain about the actual date it was opened. In another instance, an antidepressant medication was found in the wrong medication cart on the 1 [NAME] Unit. LPN 'C' identified that the medication belonged to a resident on a different hallway and removed it from the cart, placing it on top. However, LPN 'C' left the unit shortly after, leaving the medication unsecured on top of the cart. The Director of Nursing confirmed that the facility's protocol required insulin pens to be labeled with the date they were opened and the resident's name, and that medications should be accessible only to authorized personnel.
Infection Control and Dining Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for three residents. An LPN was observed not cleaning the blood pressure cuff and pulse oximetry device after use on one resident before using them on another. The LPN also failed to clean the glucometer after use and did not perform hand hygiene between resident care. Additionally, the LPN administered insulin injections and eye drops to a resident without changing gloves or washing hands between procedures. These actions were contrary to the facility's policies on cleaning and disinfection of resident-care equipment, hand hygiene, and medication administration. During a meal observation, a CNA placed a resident's breakfast tray on their lap while assisting the resident with their meal, as the overbed tray table was soiled and on the roommate's side of the room. The CNA did not express any concerns about this practice, which was against the facility's dining services policy that emphasizes hygienic practices to prevent food from coming into contact with staff clothing. The Administrator confirmed that this practice should not have occurred.
Inadequate Ventilation in Shower Room
Penalty
Summary
The facility failed to maintain adequate ventilation in the 2 East Shower Room, resulting in stale and malodorous air affecting all residents utilizing the room. On January 7, 2025, an observation revealed that the air was stagnant, and a test with tissue paper showed no suction at the ceiling vent, indicating non-functioning ventilation. Further observations on January 8, 2025, with the Plant Operations Manager and Housekeeping/Laundry Supervisor confirmed the lack of ventilation, as the toilet paper did not suction to the vent. The Plant Operations Manager acknowledged the issue but could not provide an explanation for the lack of monitoring. Maintenance logs reviewed showed no documented concerns about the ventilation, and the facility failed to provide a policy on bathroom ventilation or any relevant repair invoices by the end of the survey.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure the residents' right to receive unopened and private mail delivery was maintained for two of the eight residents who participated in a confidential resident group interview. One resident reported receiving several Christmas cards from family members that were opened upon delivery. Another resident expressed frustration over having to request their mail and experiencing delays in receiving packages, which were sometimes mixed up with staff items. This resident also reported being told that staff needed to watch them open packages to verify contents, which they felt violated their rights and privacy. The facility's Administrator was unaware of these practices and stated that mail was coordinated by the activity staff, who delivered it directly to residents. The Activity Director confirmed that packages were previously opened with residents due to concerns about medications and vapes being ordered, but acknowledged that this practice was not in line with resident rights. The facility's policies on resident rights and mail delivery emphasize the right to receive unopened mail and maintain privacy, which were not adhered to in these instances.
Failure to Educate and Offer Advance Directive to Resident
Penalty
Summary
The facility failed to educate and offer the formulation of an advance directive to a resident, identified as R28, who was admitted with diagnoses including bipolar disorder and depression. During the survey, it was observed that R28 was in their room listening to music and refused an interview. A review of R28's medical record showed no documentation that the facility had educated or offered R28 the opportunity to formulate an advance directive, as required by the facility's policy. Interviews conducted with the Social Services Manager (SSM) and the Acting Administrator (AA) revealed a lack of clarity and responsibility regarding the process of educating and offering advance directives to residents. The SSM stated that their department was only responsible for obtaining code status and not for advance directive education. The AA initially stated they would investigate the process and later confirmed that the social services department was responsible for this task, indicating that SSM H had been educated on the matter. No further explanation or documentation was provided by the end of the survey.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Agency for a resident with severe impaired cognition. The resident, who had a diagnosis of dementia, mood disorder, and delusional disorders, was observed with a dark purple/bluish bruise around their right eye and discoloration on the surrounding skin. The resident's guardian was informed by the facility that the resident had a red area on their face from sleeping on a remote, but later, the resident was sent to the hospital to rule out a facial fracture due to swelling and pain. Interviews with staff revealed that a CNA noticed the resident's face was red and imprinted from a bed remote on the morning of the incident. The unit manager assessed the resident and informed the medical doctor, DON, and the guardian. However, the condition of the resident's face worsened, showing more bruising the following day. Despite this, the facility did not report the incident as an injury of unknown origin, as they believed the injury was caused by the bed remote. The facility's administrator stated that they did not report the incident to the state agency because they assumed the injury was from the initial contact with the remote. The administrator acknowledged that the midnight nurse reported the bruising, but they did not consider it necessary to report to the state agency since they believed they knew the cause of the injury. The facility's investigation report noted the resident's tendency to bruise easily and skin integrity issues, but no further action was taken to report the injury as unknown in origin.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to adhere to the recommendation of a Level II Evaluation for a resident who was reviewed for PASARR. The resident, who was admitted with diagnoses including bipolar disorder, depression, anxiety, and schizoaffective disorder, was observed in their room but refused an interview. A letter from the Neighborhood Services Organization indicated that a Level II Evaluation was required by November 6, 2024, but a review of the medical record showed no documentation of the evaluation being completed or requested. The Social Services Manager was interviewed and acknowledged that the follow-up Level II evaluation for the resident was neither completed nor submitted. The facility's policy on Resident Assessment-Coordination with PASARR Program, revised in December 2023, mandates that all applicants be screened for serious mental disorders or intellectual disabilities, with the Social Services Director responsible for tracking each resident's PASARR screening status. Despite this policy, no further explanation or documentation was provided by the end of the survey.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services consistently met professional standards during medication administration for two residents. On the morning of January 8, 2025, an LPN was observed preparing and administering morning medications to a resident (R15) without ensuring the resident consumed them. The LPN left the room to obtain a blood pressure cuff, leaving the resident unattended and unobserved. Upon returning, the LPN proceeded to attend to the resident's roommate (R45) without verifying if R15 had ingested their medications. Additionally, the LPN administered insulin and eye drops to R45 and left a cup of pills at the bedside without confirming their consumption. The medical records for both residents revealed no documentation of a self-administration of medication assessment. The facility's policy on medication administration, dated June 2019, requires that residents be observed to ensure medication ingestion. The Director of Nursing confirmed that the LPN should have observed the residents taking their medications and should have obtained the blood sugar level before R45's meal for an accurate reading. No further explanation or documentation was provided by the end of the survey.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to ensure accurate accounting for a resident's controlled medication, specifically Hydrocodone-Acetaminophen, during a review of one of the medication carts. During an observation, it was noted that the Controlled Substance Proof-Of-Use form indicated there were 103 pills remaining, but only 101 were found in the blister pack. The LPN involved reported administering one pill to the resident and dropping another, which was then discarded in the sharps container. However, this action was not documented on the proof-of-use sheet at the time of the incident. The facility's protocol requires that when a controlled medication is wasted, a second nurse must witness the disposal and both nurses must sign off on the proof-of-use form. In this case, although the second LPN confirmed witnessing the wastage, neither nurse signed the form as required. The Director of Nursing confirmed the protocol but a policy regarding the administration of controlled substances was not provided during the survey.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident R401, who had a history of violent behavior and diagnoses including paranoid schizophrenia and bipolar disorder, punched resident R402 in the face after a disagreement over a joke. Despite R401's documented aggressive behaviors, including hitting staff and throwing objects, the facility did not take immediate action to prevent further incidents, resulting in R401 eventually being removed from the facility. Another incident involved resident R404, who had severely impaired cognition and diagnoses including major depressive disorder and delusional disorders. R404 physically assaulted resident R407, who had moderately impaired cognition, during a room transfer. Despite the altercation being witnessed by staff and reported to the police, the facility did not implement a physical behavior care plan or interventions for R404 until after a third altercation occurred. Resident R404 was also involved in two separate incidents with resident R405, who had moderately impaired cognition and diagnoses including Alzheimer's disease. R404 pushed R405 back into his wheelchair during an argument and later kicked R405 in the face. These incidents were witnessed by another resident, R409, and reported to the police. Despite these repeated incidents, the facility delayed implementing a care plan for R404's physical behaviors, failing to protect residents from further harm.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse involving several residents, including one resident who was involved in three separate incidents. The facility's policy on abuse, neglect, and exploitation requires comprehensive investigations, including interviewing all involved parties and documenting the findings. However, the investigations into these incidents were incomplete, lacking interviews with key witnesses and other residents who might have had relevant information. In one incident, a resident with severely impaired cognition was reported to have struck another resident in the face. Despite a staff member witnessing the event, the facility's investigation did not include interviews with the staff or other residents. Similarly, in another incident involving the same resident, the facility failed to interview the involved parties and witnesses, including a resident who had observed the altercations. The facility's documentation was insufficient, and the administrator admitted to not having conducted thorough interviews. Another incident involved a different resident with a history of aggressive behavior, who punched a fellow resident. The investigation into this incident was also lacking, as it did not include interviews with staff or other residents who witnessed the event. The facility's administrator confirmed the aggressive behavior but did not know the details of the incident, such as the content of a joke that allegedly provoked the altercation. Overall, the facility's failure to conduct comprehensive investigations into these incidents resulted in a lack of understanding of the root causes and potential for further abuse.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement effective interventions to prevent the elopement of a resident, identified as R406, who was at risk for elopement and had severely impaired cognition. On 9/19/24, R406 exited the facility without staff knowledge and walked approximately one and a half miles to a local police station. The resident was able to leave the facility by placing his foot in the door as a visitor exited, which allowed him to leave unnoticed. Despite being identified as an elopement risk since 5/16/24, the facility did not have adequate measures in place to prevent this incident. R406 had a history of acute necrotizing hemorrhagic encephalopathy, auditory and visual hallucinations, early onset Alzheimer's Disease, and paranoid schizophrenia. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and delusions. Prior to the elopement, R406 had been sent to the hospital on 9/17/24 due to distressing delusional and paranoid thinking, as well as aggressive behavior. Upon returning to the facility on 9/19/24, no new orders were implemented, and the resident was not provided with the necessary supervision to prevent elopement. Interviews with staff revealed a lack of communication and awareness regarding R406's elopement risk and the interventions required. LPN 'N', who was on duty during the elopement, was not informed of any additional monitoring or interventions for R406. The facility's policy on elopements and wandering residents emphasized the need for a systemic approach to monitoring and managing residents at risk for elopement, but this was not effectively executed in R406's case. The facility's failure to provide adequate supervision and implement effective interventions directly contributed to the resident's elopement.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in a resident, identified as R10, who experienced a 13.5% weight loss over a period from February 12, 2024, to May 1, 2024. R10, who was dependent on staff for most activities of daily living and had severe cognitive impairment, was observed with enteral feeding and reported weight loss. The resident's medical history included diagnoses of protein-calorie malnutrition, anorexia, COPD, depression, dysphagia, obesity, tube feeding, CHF, and hypertension. Despite these conditions, the facility's comprehensive care plan, which included monitoring weight and reporting significant changes, was not effectively implemented. The facility's records revealed that R10's weight was not documented in March 2024, and no assessments or notes were completed after a significant weight loss was recorded on April 12, 2024. The registered dietician (RD) was unaware of the weight loss until May 3, 2024, when a dietary note indicated a further weight loss and recommended adjustments to the tube feeding. The RD acknowledged issues with obtaining weights and missed alerts in the electronic medical record system, which contributed to the oversight. The facility's administrator confirmed that a problem with weight monitoring was identified in June 2024. The facility's weight monitoring policy required weights to be obtained upon admission, readmission, weekly for the first four weeks, and at least monthly thereafter. However, these procedures were not followed, leading to the failure to identify and address R10's significant weight loss in a timely manner.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for nine residents who required such measures due to their medical conditions. These residents had conditions such as pressure ulcers, urinary catheters, feeding tubes, and other indwelling medical devices, which necessitated the use of EBP to prevent the spread of infections. Observations revealed that there were no EBP signs posted, and no personal protective equipment (PPE) was available in or near the rooms of these residents. Interviews with staff members, including a Certified Nursing Assistant (CNA) and a housekeeper, indicated a lack of recent training and awareness regarding EBP. The CNA mentioned that they had been trained on EBP a long time ago, but this was the first time they had seen the signs posted. Similarly, the housekeeper stated that they had been trained on EBP quite a while ago, suggesting a gap in ongoing education and reinforcement of infection control protocols. The deficiency was further highlighted during a dressing change observation for a resident with a pressure ulcer, where the Licensed Practical Nurse (LPN) failed to don the required PPE. The LPN was unaware that EBP was required for the resident, despite the presence of a Stage III pressure ulcer with drainage. This lack of adherence to EBP protocols and insufficient staff training contributed to the facility's failure to ensure proper infection prevention and control measures were in place for residents with high-risk conditions.
Unsafe Storage of Sharp Objects in Emergency Carts
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding the storage of sharp objects in emergency carts. During observations, it was noted that four emergency carts were left unlocked, with sharp objects such as disposable razors, suture removal kits containing sterile scissors and suture forceps, and used syringes in sharps containers accessible. These carts were located in various hallways and units, including the 100 Hallway, in front of specific rooms, and the 229 Hallway. The presence of these sharp objects in unlocked carts posed an increased risk of avoidable accidents for all residents. A specific incident was observed where a resident, who was walking down the hall, approached an unlocked emergency cart, opened the top drawer multiple times, and then took a black bag containing emergency suction equipment from the top of the cart and carried it down the hall. This incident highlights the lack of adequate supervision and the potential for residents to access hazardous materials, which could lead to accidents. The Director of Nursing and an LPN Unit Manager were informed of these observations and acknowledged the issue.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for the month of May 2024, as evidenced by incomplete documentation and lack of infection control measures. The facility's policy on antibiotic stewardship, revised in January 2024, aimed to optimize infection treatment and reduce adverse events associated with antibiotic use. However, during a review on July 10, 2024, it was found that the Monthly Infection Control Log for May 2024 was incomplete, with only one resident's information fully documented. Additionally, there was no infection mapping or employee health illness log available for that month. The Director of Nursing (DON), who also served as the Infection Control Nurse, acknowledged the absence of antibiotic stewardship activities in May 2024, attributing it to the previous DON's oversight. The current DON, who started at the facility at the end of May 2024, had begun revamping the program due to its disorganized state. The facility's Administrator confirmed the issue, noting that a problem with the antibiotic stewardship program had been identified in May 2024, leading to a past non-compliance finding with a compliance date of June 1, 2024.
Failure to Respect Resident Dignity and Preferences
Penalty
Summary
The facility failed to treat two residents, R42 and R94, in a dignified manner. R42, who is cognitively intact and requires extensive assistance for most activities of daily living, reported feeling forced to take a shower despite their preference for bed baths. The facility did not have a shower chair that could accommodate R42's size, resulting in the resident having to use their regular wheelchair, which made them feel uncomfortable and unsafe. The facility's records showed inconsistencies regarding the type of bath provided, and staff interviews confirmed that R42's preferences were not respected. The facility's maintenance supervisor could not provide evidence of ordering an appropriate shower chair, and the administrator acknowledged the resident's feelings of being forced to shower. R94, who is blind, reported that some CNAs would argue with them about taking a shower or refuse to provide one. R94 could not identify the CNAs involved due to their inability to see and the CNAs not providing their names. The facility's policy on promoting and maintaining resident dignity emphasizes respecting resident preferences and ensuring staff report and document such preferences. However, the facility failed to adhere to this policy, resulting in a lack of respect for R94's dignity and preferences.
Failure to Report Alleged Abuse Threat
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, where one resident threatened another with a fork. The incident was reported by the threatened resident to multiple staff members, including the Social Worker, but was not documented in the resident's clinical record or reported to the Abuse Coordinator and the State Agency. The resident who made the threat was later sent out for psychiatric evaluation due to an acute behavior change, but the initial threat was not properly addressed or investigated by the facility. The resident who reported the threat was cognitively intact, as indicated by a BIMS score of 15/15, and had a medical history including type II diabetes, heart failure, and bipolar disorder. The resident who made the threat also had a relatively intact cognition with a BIMS score of 13/15 and was diagnosed with schizophrenia, anxiety, and delusional disorders. Despite the Social Worker being aware of the threat and informing the Administrator, the facility's policy on abuse reporting was not followed, as the Administrator claimed they were not informed of the incident.
Failure to Update and Implement Resident's Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was revised and modified to reflect a resident-centered and individualized plan of care for a resident identified as R10. Observations over three consecutive days revealed that R10, who had a history of falls, was not provided with a concave mattress or floor mats as indicated in their care plan. Despite having a physician's order for a concave mattress dated several months prior, these interventions were not present in R10's room during the observations. R10 was admitted with diagnoses including Protein Calorie-Malnutrition and Anorexia and was dependent on staff for most activities of daily living, with a severely impaired cognition as indicated by a BIMS score of four. The care plan initially included interventions for fall prevention, such as a concave mattress and floor mats, but these were not implemented. The Nurse Manager acknowledged that the interventions were removed due to a change in R10's fall risk status, but the care plan was not updated to reflect this change, leading to the deficiency.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure nursing services met professional standards for medication administration documentation for a resident. The resident, who was cognitively intact with a BIMS score of 15/15, had diagnoses including diabetes, right below the knee leg amputation, morbid obesity, atrial fibrillation, and hypertension. During an observation of medication administration, an LPN presented the resident with ordered medications, Eliquis and Ferrous Sulfate, which the resident refused. However, a subsequent review of the Medication Administration Record (MAR) revealed that the LPN had documented these medications as administered. Upon interview, the LPN confirmed that the medications were not given and acknowledged the documentation error, attributing it to nervousness during the observation. The Director of Nursing was informed of the incident and confirmed the documentation error.
Failure to Provide Shaving Per Personal Preference
Penalty
Summary
The facility failed to provide shaving per personal preference for two residents, R94 and R54, who were reviewed for activities of daily living (ADLs). R94, who is blind and has severely impaired vision, expressed a desire to be clean-shaven but reported that some Certified Nursing Assistants (CNAs) refused to shave him and did not disclose their names. Observations on 7/8/24 showed R94 with stubble, but by 7/9/24, he was clean-shaven after receiving assistance the previous night. R94's clinical record indicated he was cognitively intact and required staff assistance for ADLs. Similarly, R54, who has moderately impaired cognition and is dependent on staff for ADLs, was observed with a full beard on 7/8/24, despite his preference to be clean-shaven. By 7/9/24, R54 was observed to be clean-shaven and expressed satisfaction with his appearance. Interviews with CNA I and the Director of Nursing (DON) revealed that residents are typically shaved during showers or upon request, aligning with the facility's policy on ADLs, which mandates necessary services for grooming and personal hygiene for residents unable to perform these activities themselves.
Failure to Monitor Blood Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to consistently monitor blood glucose levels for a resident with type 2 diabetes, leading to a potential risk of complications from abnormal blood sugar levels. The resident, who had a history of diabetes, anxiety disorder, depression, diabetic neuropathy, and chronic kidney disease, was readmitted to the facility after a recent hospitalization. Despite having unstable blood sugars prior to hospitalization and being on sliding scale insulin, there were no orders to monitor the resident's blood sugar after readmission. The resident's electronic medical record and physician progress notes indicated the need for blood glucose monitoring, yet no such monitoring was conducted for 12 days following readmission. The resident's blood sugar levels were previously monitored multiple times a day, and they were receiving sliding scale insulin. However, after readmission, the facility did not continue this monitoring, and the resident experienced a cardiac arrest and expired at the facility. Interviews with the Director of Nursing, Unit Manager, and Nurse Practitioner revealed a lack of clarity and communication regarding the resident's blood sugar monitoring. The Nurse Practitioner mentioned that the resident's hemoglobin A1c was within normal limits, leading to the discontinuation of insulin, but there was no documentation to support this decision. Additionally, the facility failed to provide a policy or protocol on blood sugar monitoring when requested by the surveyor.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide an appropriate support surface bed for a resident, resulting in the development of an avoidable unstageable pressure ulcer. The resident, who was admitted with medical conditions including opioid abuse, hypertension, anemia, chronic kidney disease, and rheumatoid arthritis, was independent with activities of daily living and had a BIMS score indicating cognitive intactness. Despite the resident's repeated verbal complaints about the inadequate support from the bed mattress and the pressure applied by the bed frame bar, no corrective action was taken by the facility staff. The resident developed a pressure ulcer on the left buttock, which was not present upon admission. The wound was observed to be a Stage III pressure ulcer with moderate seropurulent drainage and a pink, macerated wound bed. The dressing change orders were not consistently followed, as evidenced by the discrepancy between the documented dressing change schedule and the actual dressing change observed. The resident expressed dissatisfaction with the care provided, noting that the dressing was not changed daily as required. The facility's maintenance records did not document any requests regarding the bed issue, and the staff, including the maintenance manager and wound care provider, were not adequately informed or responsive to the resident's complaints. The Director of Nursing was made aware of the facility-acquired pressure ulcer, and the facility's policy on skin and pressure injury risk assessment and prevention was not effectively implemented, as it included providing appropriate pressure-redistributing support surfaces.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to maintain or prevent further decline in range of motion for a long-term resident, identified as R3, who was admitted with diagnoses including seizures, stroke, osteoarthritis, abnormal posture, and muscle weakness. Observations revealed that R3 had significant cognitive impairment and was often found in bed with a contracted right hand and elbow, without any braces or palm protectors as prescribed. The resident's care plan included orders for a soft carrot or palm protector and a hand splint to be applied daily, but these were not consistently implemented. During multiple observations over two days, R3 was repeatedly seen without the prescribed brace or palm protector, despite the care plan and physician orders indicating their necessity to maintain skin integrity and prevent further contracture. Interviews with staff, including a CNA and the DON, revealed a lack of adherence to the care plan, with the CNA unable to locate the brace and the DON acknowledging that nurses were supposed to ensure CNAs followed the orders. The facility's policy required systematic assessment and care planning to prevent decline in range of motion, but this was not effectively executed for R3. The facility's documentation indicated that staff were signing off on tasks related to the application of the palm protector, despite it not being applied during the surveyor's observations. The DON and unit manager were informed of the discrepancies, and both acknowledged the concern, indicating a failure in monitoring and ensuring compliance with the care plan interventions. This lack of implementation and oversight resulted in a potential for further decline in R3's range of motion or worsening of contracture.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), as evidenced by the lack of assessment and care planning for the condition. The resident, who also had a history of stroke with left side paralysis and schizophrenia, was observed with physical limitations and moderately impaired cognition. Despite these conditions, the facility did not conduct a trauma-informed care assessment upon the resident's admission or readmission, nor did they develop a care plan to address the PTSD diagnosis. Interviews with the Social Work Director and the Administrator revealed that the trauma-informed care assessment, which should have been completed by Social Work, was not conducted. Consequently, no care plan was implemented to identify and mitigate potential PTSD triggers for the resident. The facility's policy on trauma-informed care emphasized the importance of identifying a resident's history of trauma and cultural preferences, yet this was not adhered to in the case of the resident in question.
Failure to Document Physician's Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure a record of the attending physician's response to pharmacy recommendations for a resident reviewed for monthly medication regimen reviews. The resident, who was admitted with diagnoses including dementia, breast cancer, and anorexia, had a moderate impaired cognition with a BIMS score of 9/15. A monthly Medication Regimen Review dated February 15, 2024, was noted in the resident's electronic record, but no report or response was found. The Director of Nursing, who was new to the facility, was unable to locate the report or identify the concern related to the MRR. Additionally, the facility did not provide a policy pertaining to MRRs by the end of the survey.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 6.9%. This deficiency was identified during an observation of medication administration for a resident, where two medication errors were noted out of 29 opportunities. On the specified date, an LPN was observed administering medications Eliquis and Ferrous Sulfate to the resident, who refused them. However, the Medication Administration Record (MAR) indicated that these medications were documented as administered at an earlier time, despite the resident's refusal. The LPN later confirmed that the medications were not given, yet they were signed off as administered. The Director of Nursing was informed of this discrepancy, which was a violation of the facility's medication administration policy that requires documentation and explanatory notes for doses not administered.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, R63 and R65, as ordered by their physicians. Resident R63, who was admitted with diagnoses including dementia and breast cancer, was receiving Depakote and required monitoring of valproic acid levels. Despite a pharmacy recommendation on 4/7/24 and a subsequent physician's order on 4/8/24, no laboratory results for valproic acid levels were found in the resident's clinical record. The Director of Nursing (DON) confirmed the absence of these results during an interview on 7/9/24 and was unable to obtain them by 7/10/24. Similarly, Resident R65, diagnosed with paraplegia and muscle weakness, also required valproic acid level monitoring. A pharmacy recommendation on 3/7/24 led to a physician's order on 3/27/24 for various lab tests, including valproic acid levels. However, no results were available until after a repeat order on 4/19/24, with results finally obtained on 4/26/24 showing low valproic acid levels. The DON was unable to explain the month-long delay in obtaining these laboratory diagnostics. The facility's policy mandates timely provision of laboratory services, which was not adhered to in these cases.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by offensive odors, overflow of garbage, soiled floors, and broken equipment. Upon entering the facility, a strong foul odor of urine and feces was noted, and the common area floors were sticky and visibly soiled. Medical exam gloves and condiment wrappers were observed on the floor. In resident rooms, such as those of R902 and R903, there were odors of spoiled milk, dried food matter, overflowing trash receptacles, and scattered clothing and food crumbs on the floor. The [NAME] Unit shower room had soiled utility towels, an overflowing sharps container, and unsanitary conditions in the toileting area, including dried urine and a broken hand soap wall mount. The Central Unit Shower was cluttered with equipment and had dried brown matter on the walls and floor, along with broken hand soap dispensers and no paper towels available. Housekeepers reported being short-staffed, with only one housekeeper for the entire second floor and no housekeeping staff over the weekend. This led to significant cleanliness issues, including soiled briefs left in the shower and overflowing trash receptacles. Housekeeper C mentioned that she was originally hired as a laundry aide but was working as a housekeeper due to staffing shortages. Housekeeper B indicated that the strong urine odor in the locked unit was due to residents with dementia urinating in inappropriate places. The facility lacked documentation for work orders, cleaning schedules, and policies for storage and cleaning, as confirmed by the Nursing Home Administrator. The facility activity room had a rotten food odor from an overflowing trash receptacle filled with empty soda cans, chips, candy wrappers, and uneaten food, attracting small flies. A surveyor slipped on a piece of bread surrounded by a red substance near the [NAME] shower room. The second floor had a strong urine odor in common areas and near residents eating breakfast, with sticky, visibly soiled floors and overflowing trash receptacles. The facility environment manager was unavailable for an interview, and the Nursing Home Administrator confirmed the lack of specific cleaning policies and tracking sheets for the shower rooms.
Failure to Monitor and Supervise Resident with Alcohol Addiction
Penalty
Summary
The facility failed to provide necessary monitoring, supervision, and interventions for a resident with a known alcohol addiction. The resident, who had diagnoses including dementia, dysphagia, and alcohol abuse, was admitted with a history of alcohol withdrawal. Despite having intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs), the resident frequently left the facility on Leave of Absence (LOA) and returned intoxicated. Staff documented multiple instances of the resident leaving and returning intoxicated, including an episode where the resident was agitated and throwing objects, necessitating a visit to the emergency room for safety concerns. However, no care plans or interventions were implemented to address the resident's alcohol addiction or to monitor and supervise their LOA returns. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that although the issue was discussed in morning meetings, no formal care plans or interventions were put in place. The DON and Social Service Manager acknowledged the lack of implemented care plans and interventions for the resident's alcohol addiction and LOA returns. The facility's failure to provide adequate supervision and monitoring for the resident's known alcohol addiction led to the deficiency cited in the report.
Failure to Protect Residents from Abuse and Misappropriation of Funds
Penalty
Summary
The facility failed to protect two residents, R902 and R906, from physical abuse by another resident, R911. The incidents were reported to the state agency, and an onsite investigation was conducted. During interviews, R911 admitted to provoking R906, which led to a physical altercation. The Director of Nursing (DON) and a Registered Nurse (RRN) acknowledged that despite their efforts, they could not prevent the residents from interacting and that the incidents were substantiated as abuse after their investigation. R906 initially denied any incident but later confirmed that R911 attempted to hit her, and staff intervened to separate them. The facility also failed to protect R906 from misappropriation of funds by a staff member, CNA J. During an interview, CNA J described how he discovered his missing backpack and other items in R906's room, including $105 in a tin cookie can. R906 claimed that $40 was missing, which the facility took seriously. The DON and RRN confirmed that the allegations were substantiated as abuse, although they acknowledged that R906 had a history of stealing and lying. The facility's response to CNA J's initial report of the missing items was inadequate, as the DON did not provide immediate guidance, and CNA J had to wait for further instructions. The facility's failure to protect residents from abuse and misappropriation of funds highlights significant deficiencies in their ability to ensure a safe environment. The DON and RRN admitted that their efforts to manage the residents' interactions were insufficient, and the facility's response to the staff member's report of missing items was delayed and ineffective. These deficiencies were substantiated by the facility's own investigations and the observations made during the onsite survey.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This deficiency was identified in an incident involving two residents, where one resident made verbal sexual requests to another. The incident occurred on January 11, 2024, but was not reported to the State Agency until February 20, 2024, well beyond the required 24-hour reporting window. The facility's own policy mandates that all alleged violations be reported to the State Agency within 24 hours if the events do not involve abuse and do not result in serious bodily injury. Resident R903, who was cognitively intact with a BIMS score of 14, expressed frustration when interviewed about the incident and confirmed feeling safe around the other resident involved, R902. Resident R902, who has moderate cognitive impairment with a BIMS score of 8, was also interviewed and stated that he respects the female residents. The delay in reporting was confirmed by the RN Regional Clinical Director, who acknowledged that the facility had outstanding Facility Reported Incidents (FRIs) from January 2024 that were not completed in a timely manner. This failure to report in accordance with guidelines resulted in the potential for unidentified or continued abuse.
Failure to Investigate Allegations of Theft and Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of stolen money from one resident and verbal abuse by a staff member towards another resident. Resident R907 reported that CNA J entered his room and accused him of stealing items that were later found in another resident's room. Although R907 did not feel threatened, his mother insisted on reporting the incident. CNA J admitted to asking R907 about the missing items but denied using profane language, a claim supported by Nurse K, who was present during the interaction. The Director of Nursing (DON) was not aware of the incident until two days later and did not conduct a thorough investigation, relying instead on written statements from staff members involved. The corporate administrator was notified but did not follow up adequately, leading to a lack of proper documentation and resolution of the incident. Additionally, the facility failed to address the theft of $75 from Resident R905 by Resident R906. The DON acknowledged that R906 had a history of taking items but did not take appropriate action to investigate or resolve the issue. The administrator later stated that R905 would be reimbursed, but this decision came after the surveyors' exit and was not part of the initial response to the incident. The lack of a timely and thorough investigation into both incidents highlights deficiencies in the facility's handling of resident complaints and staff conduct. The report also revealed that staff members were unclear about where to store their personal items, leading to confusion and potential security issues. CNA J's belongings were initially placed in a common area, which may have contributed to the theft. The facility's failure to provide clear guidelines and secure storage options for staff personal items further exacerbated the situation. Overall, the facility's inaction and inadequate response to the reported incidents demonstrate significant lapses in their investigative and administrative processes.
Failure to Follow AMA and LOA Policies
Penalty
Summary
The facility failed to follow its policies for Leave Of Absence (LOA) and Against Medical Advice (AMA) discharge for a resident identified as R913. On 3/7/24, the resident was noted to be out on LOA but had not returned by the end of the evening shift. The Licensed Practical Nurse (LPN) on duty reported the absence to the Director of Nursing (DON), who instructed the LPN to document the resident's absence if they had not returned by the end of the shift. However, there was no physician's order for the LOA, and the required Release of Responsibility for Leave of Absence form was not signed by the resident or the supervising person. Additionally, the DON and the Social Service Manager (SSM) failed to document the resident's irate behavior and the AMA discharge properly. The AMA form was incomplete, lacking the resident's initials on critical sections, and the physician was not notified before the resident left the facility. The DON and SSM admitted to not following the facility's policies regarding AMA discharges. The SSM did not educate the resident on the risks of leaving AMA or notify the physician, and the DON forgot about the AMA form provided by the SSM. The nursing staff were under the impression that the resident was on LOA, and the DON gave directives based on this incorrect assumption. The DON's documentation on 3/8/24 initially stated the resident was on LOA but later mentioned the AMA discharge, indicating confusion and lack of proper communication. The facility's failure to adhere to its AMA and LOA policies resulted in inadequate documentation and communication regarding the resident's status. The resident's medical record lacked proper documentation of the AMA discharge, and the required procedures for informing and educating the resident and notifying the physician were not followed. This deficiency highlights significant lapses in the facility's adherence to its policies and procedures, leading to potential risks for the resident's safety and well-being.
Failure to Revise Care Plan After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to revise the care plan for a resident (R908) who exhibited aggressive behavior towards another resident (R909). The incident involved R908 pulling the hair of R909 without any prior verbal exchange or provocation. Despite the incident being witnessed by a Certified Nursing Assistant (CNA I) and documented in a Facility Reported Incident (FRI), the facility did not update R908's care plan to include interventions to prevent further resident-to-resident mistreatment. Additionally, there was no documentation indicating that the interdisciplinary team met to discuss R908's behavior and modify or implement care plan interventions to ensure the safety of other residents. R908 was admitted to the facility with diagnoses including dementia, hallucinations, and schizoaffective disorder. The existing care plans for R908 included potential for physical behaviors and extremely aggressive behavior towards staff, but no interventions were added following the incident with R909. The Regional Clinical Director (RCD A) acknowledged the concern when interviewed but provided no further explanation or documentation by the end of the survey.
Failure to Provide Behavioral Health Services for Resident with Alcohol Dependence
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of alcohol dependence and abuse. The resident was observed returning to the facility intoxicated on multiple occasions, and the facility did not have a plan in place to address the resident's substance use disorder. The social worker admitted that no internal planning was done for residents with substance abuse issues, and the only measures offered were external treatments and classes, which the resident did not participate in. Despite the resident's known diagnosis and repeated intoxication, the facility allowed the resident to leave the premises unsupervised, leading to further alcohol consumption. Interviews with the social worker and the Director of Nursing revealed a lack of coordinated efforts to manage the resident's condition. The social worker initially claimed that the resident's leave of absence (LOA) privileges had been restricted but later retracted this statement, confirming that the resident was still allowed to leave the facility. The Director of Nursing deferred responsibility to the social worker, who had not implemented any specific interventions for the resident's alcohol abuse. The facility's failure to provide adequate behavioral health services and to restrict the resident's access to alcohol resulted in ongoing substance abuse issues within the facility.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
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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