Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Belding, Michigan.
- Location
- 414 E State Street, Belding, Michigan 48809
- CMS Provider Number
- 235357
- Inspections on file
- 25
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with dementia and wandering behaviors repeatedly entered the rooms of other residents, despite care plans and staff attempts at redirection. On one occasion, this led to a physical altercation in which another resident sustained facial injuries and significant distress. Staff interviews revealed ongoing challenges with supervision, lack of effective interventions, and insufficient activities, contributing to the failure to protect residents from abuse.
The facility did not provide a meaningful activity program for cognitively impaired residents on the locked unit, leaving many unengaged and without posted activity schedules. Two residents with significant behavioral and cognitive needs were not provided with appropriate activities, leading to increased agitation and a physical altercation. Staff interviews confirmed that activities were often not conducted due to staffing shortages, and documentation of interventions was incomplete.
The facility did not conduct a thorough investigation into an alleged resident-to-resident abuse incident, as required by its policy. Although two residents were involved in a physical altercation resulting in injury, staff members who were present at the time were not interviewed or asked to provide statements, and there was no documentation of potential witnesses.
A resident with dementia and a history of falls was able to leave the facility unsupervised and was found in the parking lot attempting to open car doors. The resident was not under 1:1 supervision and did not have a WanderGuard device at the time, and staff were unable to determine exactly how the resident exited the building. The resident was outside for several minutes before being redirected back inside, with no reported injuries.
The facility failed to ensure call lights were within reach for five residents, despite care plans and assessments indicating their necessity. Observations revealed that call lights were consistently out of reach for residents with Alzheimer's, dementia, and other conditions, contrary to facility policy requiring staff to ensure accessibility during each interaction.
The facility failed to follow professional standards in administering treatments and medications for four residents. One resident missed multiple skin treatments, while another did not receive a scheduled pain medication dose without documentation or provider notification. A third resident missed an anxiety medication dose, and a fourth received insulin despite low blood sugar levels. An internet outage contributed to these issues, affecting the use of the Electronic Medical Record system.
A resident with severe cognitive impairment was allowed to self-administer hydrocortisone cream without an assessment by the interdisciplinary team, contrary to facility policy. The resident, who did not know the name of the cream, was left with the medication in his room, and staff had not documented any evaluation of his ability to safely self-administer the medication.
The facility failed to follow physician orders for daily weight monitoring and medication administration for two residents with CHF. One resident did not have weights recorded on several dates, and significant weight increases were not reported to the provider. Another resident did not receive as-needed Lasix despite weight gain. The DON confirmed the lapses in care, attributing them to assumptions made by nursing staff and a lack of specific CHF management policies.
Two residents experienced falls due to the facility's failure to follow care plans. One resident with Huntington's Disease was transferred by a single CNA instead of two, resulting in a fall and injuries. Another resident, who required assistance with a walker and gait belt, was observed walking independently without a gait belt. These incidents demonstrate non-compliance with care plans and facility policies.
The facility failed to thoroughly explain the arbitration agreement to two residents during the admission process. A visually impaired resident was not offered an audio explanation, and another resident with quadriplegia could not recall the details of the agreement. Both residents indicated that the agreement was not adequately explained, leading to a deficiency in the facility's admission process.
The facility failed to report alleged abuse within the required two-hour timeframe for four residents. An incident involving two residents was reported to the NHA four days late, and another incident was delayed due to the NHA's lack of internet access. The facility's policy requires immediate reporting, which was not followed.
The facility failed to properly monitor and treat the conditions of two residents, leading to severe outcomes including ICU admission and delayed treatment. Additionally, the facility did not ensure proper coordination of hospice services, complete wound treatments as ordered, or maintain a functioning air mattress for other residents.
The facility failed to ensure a dignified dining experience and proper hand hygiene for several residents. Staff were observed standing over residents while assisting them with meals, moving between them without practicing proper hand hygiene. One resident waited 20 minutes to be served his meal, and another was intermittently assisted while the CNA was focused on her phone.
The facility failed to provide meaningful activities to a resident with severe cognitive impairment and all residents in the S-1 and S-2 memory care units. Observations showed residents unengaged, and interviews revealed that staffing cuts significantly impacted the ability to provide activities. The activities calendar showed limited scheduled activities, with some only performed outside the memory care units.
A resident with severe cognitive impairment and a history of falls experienced multiple falls over a 60-day period due to the facility's failure to provide consistent assistance with mobility, transferring, and toileting. Despite physical therapy recommendations and various interventions, the resident continued to fall, resulting in minor injuries.
The facility failed to safeguard a resident's medical records, accurately document a guardian's name, obtain a proper signature on a Medical Treatment Decision Form, and ensure timely documentation by a PA, leading to potential impacts on resident care and confidentiality breaches.
The facility failed to maintain an effective QAPI committee, resulting in repeated deficiencies and undesired outcomes for residents. Surveyors observed residents in the memory care unit with no meaningful engagement and found quality of care issues such as unmonitored weight loss and lack of coordination with hospice. The DON acknowledged the issues but stated that the QAPI committee felt it was meeting regulatory expectations and had no performance improvement plans in place.
The facility failed to maintain adequate ventilation, resulting in stagnant, humid air and unpleasant odors in the North Hall. Observations revealed non-functioning exhaust vents in the shower room and bathrooms of two resident rooms. The Maintenance Director stated that the ventilation system is inspected twice a year and that the North halls have a separate rooftop unit from the South Halls.
The facility failed to ensure CNAs completed a minimum of twelve hours of in-service training annually. CNA D had 5.25 hours of training, CNA E had no record of in-service hours, CNA Q had 1 hour of training, and CNA X had 2 hours of training. Abuse and dementia training were either incomplete or initiated only after the survey began. The DON confirmed that Human Resources tracks employee in-service training.
The facility failed to obtain informed consent from the responsible parties of two residents before administering psychotropic medications. One resident was given Zyprexa without the legal guardian's knowledge, and another was given Lorazepam without the DPOA's awareness. Documentation errors and lack of timely communication were identified.
The facility failed to provide a clean, comfortable, and homelike environment for a resident with multiple medical conditions, resulting in potential safety hazards and compromised care. The resident's room was cluttered, obstructing access to the bed and oxygen concentrator, and there was no consistent documentation of interventions to address the clutter.
The facility failed to revise care plans for two residents and implement necessary revisions for one resident. One resident with severe cognitive impairment and a history of falls did not receive the required assistance, leading to multiple falls. Another resident experienced significant weight loss and edema, but the care plan was not updated to address these issues. A third resident, dependent on staff for eating, was not provided the necessary adaptive equipment and one-to-one assistance, compromising their care.
The facility failed to ensure proper medication administration for three residents. A nurse allowed a resident's husband to administer medications without staying in the room, another nurse left a resident unattended during a breathing treatment, and an IV antibiotic was administered outside of the physician-prescribed orders.
The facility failed to provide restorative nursing services for a resident with severe cognitive loss and multiple medical conditions, resulting in the potential for a decline in the resident's condition. Despite the need for range of motion (ROM) exercises, the resident's care plan and physician orders did not include any mention of such services, and the facility did not have a restorative nursing program in place.
A resident experienced significant weight loss due to the facility's failure to assess and monitor weight changes. Despite the resident's care plan to maintain nutritional status, the weight loss was not addressed, and no follow-up weight monitoring was conducted after diuretic treatment. The Registered Dietitian dismissed the weight loss warning based on an unverified hospital weight record.
A facility failed to follow accepted standards of practice for a PICC line dressing change for a resident with multiple health issues, resulting in improper hand hygiene, lack of use of a sterile barrier, and failure to measure the external catheter length. The nurse did not adhere to the facility's policy on central venous catheter dressing changes, as confirmed by nurse managers.
The facility failed to ensure unobstructed access to an oxygen concentrator and provide proper humidification for a resident with COPD and chronic respiratory failure. The resident's oxygen equipment was inaccessible due to clutter, and the humidification bottle was found empty, causing discomfort and potential respiratory distress.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant decline in health, which was not timely documented or acted upon by the facility's medical provider. Despite observable changes in the resident's condition, the provider did not order additional monitoring or lab work. The resident was later hospitalized with severe sepsis and other critical conditions, raising concerns about potential neglect.
The facility failed to provide medically-related social services for a resident, resulting in the resident not having current up-to-date guardianship documentation. The resident had multiple diagnoses and moderate cognitive impairment, but the temporary guardianship order for the primary contact had expired, and no updated documentation was available.
A resident with severe cognitive impairment was not properly monitored for psychotropic medication side effects, leading to hospitalization in critical condition. The facility failed to document Risk versus Benefit analyses for prescribed medications and did not act on documented signs of adverse effects.
The facility failed to publicly post nurse staffing data as required. The daily staff posting was found inside a binder at the main Nurses Station, but it was not publicly posted, and the binder did not indicate that it contained public information.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Ineffective Interventions
Penalty
Summary
A resident with a history of dementia, behavioral disturbances, and wandering behaviors repeatedly entered other residents' rooms, including that of another resident who was cognitively intact but had a history of behavioral and physical aggression. The care plan for the resident with dementia identified risks for wandering, impaired safety awareness, and lack of personal boundaries, with interventions such as redirection and offering diversions. Despite these interventions, documentation shows that the resident continued to wander, enter other residents' rooms, and exhibit exit-seeking behaviors. Staff notes indicated that the resident was not effectively redirected and that interventions to address aggressive behavior were not always documented or effective. On the day of the incident, there were no planned activities on the unit, and staff struggled to keep the resident with dementia occupied. Multiple staff interviews confirmed that the resident was in and out of rooms, taking items, and that other residents were becoming agitated by these intrusions. Staff attempted to redirect the resident with various activities, but these efforts were short-lived and did not prevent further wandering. The resident ultimately entered the room of another resident, resulting in a physical altercation where the cognitively intact resident sustained a bruise and skin tear to the face, as well as significant pain and distress. Interviews with staff and the affected resident revealed that the resident with dementia had been entering the same room multiple times over several days, and the affected resident had repeatedly reported this to staff without effective resolution. Staff acknowledged that 15-minute checks were routine and not a significant new intervention, and that the lack of activities and high resident acuity made supervision difficult. The facility's policy required identification, assessment, and intervention for residents at risk of conflict, but documentation and staff actions did not demonstrate effective implementation of these measures, resulting in physical and psychosocial harm to the resident who was assaulted.
Failure to Provide Meaningful Activities for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a meaningful activity program for cognitively impaired residents on the locked unit, as well as for two sampled residents. Observations revealed that, at multiple times, residents were left unengaged in common areas, with only one activity assistant present and no other staff facilitating activities. Activity calendars were not posted in the hallways, common areas, or resident rooms, and where a calendar was present, it was left blank. Scheduled activities were not carried out as planned, and there was no system in place to indicate which activities had been completed or canceled. Staff interviews confirmed that activities were often not happening, particularly on the locked unit, and that staffing shortages contributed to the lack of engagement for residents. Two residents were specifically identified as being affected by the lack of meaningful activities. One resident, with a history of bipolar disorder, frontotemporal neurocognitive disorder, and other mental health diagnoses, was noted to have behaviors such as talking to themselves, agitation, and a history of physical aggression. The care plan for this resident included interventions to analyze triggers and de-escalate behaviors, but there was no evidence that meaningful activities were provided to address these needs. Another resident, with unspecified dementia and behavioral disturbances, was described as physically active, social, and in need of frequent one-on-one attention. This resident exhibited wandering, exit-seeking, and intrusive behaviors, and staff struggled to find activities to keep him occupied. Attempts to redirect him with simple tasks were only briefly effective, and documentation of interventions and outcomes was incomplete. Staff interviews further highlighted the deficiency, with multiple CNAs and LPNs reporting that there were no planned activities on the unit and that they struggled to keep residents engaged. Staff described increased resident agitation and behavioral incidents, including a physical altercation between two residents, which occurred in the absence of meaningful activities. The facility's own policy required ongoing activity programs tailored to residents' needs and preferences, including special considerations for those with dementia, but these requirements were not met as evidenced by the observations, interviews, and record reviews.
Failure to Conduct Thorough Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of resident-to-resident abuse involving two residents. One resident, who was moderately cognitively impaired with a history of dementia and behavioral disturbances, entered another resident's room and a physical altercation occurred, resulting in physical contact and injury. Both residents claimed to have been struck by the other, and immediate interventions such as separation, 15-minute checks, and notifications to appropriate parties were implemented. However, the investigation report did not include statements from staff members who were present and working with the residents at the time of the incident. Multiple staff members, including CNAs and nurses who were on duty during the event, reported during interviews that they were not asked to provide statements for the investigation. The facility's policy requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, but there was no evidence that this was done. The investigation also lacked documentation regarding the presence of visitors or other employees who may have witnessed the incident, resulting in an incomplete investigation as required by facility policy.
Resident Elopement Due to Lapse in Supervision
Penalty
Summary
A resident with vascular dementia, aphasia, and a history of falls was admitted to the facility and was not her own responsible party. On the date of the incident, the resident was found outside the facility in the parking lot, unsupervised. The resident was observed by a recreation department staff member and an activity aide, who noted that the resident was attempting to open car doors and expressed a desire to go home and see her family. The staff member spent several minutes convincing the resident to return inside the facility. The facility was unable to determine with certainty how the resident exited the building, but it was believed that she left through a door near the parking lot. At the time of the incident, the resident was not under 1:1 supervision and did not have a WanderGuard device in place. The resident was unsupervised for approximately 3 to 4 minutes before being found and redirected back into the facility. There were no reported injuries or lasting harm as a result of the incident. Interviews and record reviews confirmed that the resident was able to leave the facility without staff supervision, and the facility acknowledged that the resident eloped. The incident highlighted a lapse in supervision and monitoring for a resident with known cognitive impairment and elopement risk, resulting in the resident's unsupervised exit from the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents who were assessed or care planned for their use. Resident #294, a female with Alzheimer's and other health issues, was observed multiple times with her call light out of reach, despite her care plan specifying the need for an accessible call light to reduce fall risk. Similarly, Resident #32, a male with Alzheimer's and other conditions, was repeatedly observed with his call light out of reach, contrary to his care plan that required personal items and the call light to be within reach. Resident #70, a female with a history of falls and severe cognitive impairment, had no safety interventions involving the call light in her care plan, and her call light was consistently out of reach. Resident #14, a female with dementia and other health issues, was unable to reach her call light, which was wrapped around the bed rail. Resident #9, a female with dementia and anxiety, was observed with her call light out of reach and was unable to locate it. The facility's policy required staff to ensure call lights were within reach during each interaction, but this was not adhered to, as evidenced by the observations and interviews conducted.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in the administration of treatments and medications for four residents. For one resident, there were multiple instances where skin treatments were not documented as completed, indicating they may not have been administered. Another resident did not receive a scheduled dose of a controlled pain medication, with no documentation explaining the omission or notification to the provider. Similarly, a third resident did not receive a scheduled dose of a controlled medication for anxiety, with no documentation or provider notification regarding the missed dose. Additionally, a fourth resident received insulin injections despite blood sugar levels being below the specified threshold for withholding the medication. The Director of Nursing reported that the facility's Unit Managers were expected to identify missed medications or treatments daily, but an internet outage on a specific date hindered the use of the Electronic Medical Record system, contributing to the medication administration issues. The facility's policy requires medications to be administered according to prescriber orders and within a specific time frame, which was not adhered to in these cases.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment for self-administration of prescription medication for a resident diagnosed with dementia and chronic obstructive pulmonary disease. The resident, who was admitted to the facility with a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, was observed with two medication cups containing a white cream in his room. The resident reported that staff left the cream for him to apply to a rash on his chest, although he did not know the name of the cream. A Registered Nurse (RN) confirmed that the resident had an order for staff to apply hydrocortisone cream to the rash, but the resident insisted on applying it himself. The RN admitted to leaving the cream in the resident's room without the interdisciplinary team discussing or determining the resident's safety in self-administering the medication. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record (EMR) of an assessment to determine the resident's capability to self-administer the cream, which was against the facility's policy that requires an interdisciplinary team assessment before allowing self-administration of medication.
Failure to Implement Physician Orders for CHF Residents
Penalty
Summary
The facility failed to implement physician's orders for daily weight monitoring and medication administration for two residents with congestive heart failure (CHF). Resident #17, a female with acute on chronic combined systolic and diastolic CHF, had orders for daily weights and to report significant weight changes to her physician. However, weights were not recorded on several specified dates, and there was no documentation that the provider was notified of weight increases exceeding 2-3 pounds in one day, which could indicate worsening heart failure. Similarly, Resident #89, a male with chronic combined systolic and diastolic CHF, had orders for daily weights and as-needed Lasix for weight gain. Weights were not obtained on several dates, and the as-needed Lasix was not administered despite significant weight increases. The Director of Nursing (DON) confirmed that the weights were not obtained daily for both residents and acknowledged that licensed nurses were responsible for ensuring daily weights and monitoring weight trends. The DON identified that the inconsistency in obtaining weights was due to nursing staff assuming that certified nursing assistants had completed the task without verification. The facility lacked a specific policy or procedure for managing residents with CHF, contributing to the oversight in care. The report highlights the importance of accurate weight monitoring as an indicator of fluid status and the need for adherence to physician orders to manage CHF effectively.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that residents were transferred according to their care plans, leading to accidents involving two residents. Resident #66, a male with Huntington's Disease and a history of falls, was supposed to be transferred with the assistance of two staff members using a gait belt. However, a CNA attempted to transfer him alone, resulting in the resident falling and sustaining multiple injuries, including lacerations and abrasions. The incident occurred when the resident attempted to reposition himself after being transferred, and the CNA was unable to prevent the fall due to the lack of a second staff member. Resident #78, who was severely cognitively impaired and required assistance with ambulation using a wheeled walker and gait belt, was observed walking independently in the hallway. A CNA assisted the resident to a chair without using a gait belt, contrary to the care plan requirements. The CNA acknowledged the oversight, and the facility's policy mandates the use of gait belts for residents who cannot ambulate independently. These incidents highlight the facility's failure to adhere to care plans and policies designed to prevent accidents.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, leading to a deficiency in the admission process. Resident #58, a visually impaired female with glaucoma, was not given the opportunity to listen to an audio recording explaining the arbitration process for visually impaired residents. During her admission, she allowed administrative personnel to electronically sign the forms on her behalf, but she did not recall being informed about the arbitration agreement. The staff member responsible for the admission process admitted to not reading every paragraph of the agreement to the resident and was advised by corporate to provide only a brief explanation of the forms. Resident #88, a cognitively intact male with quadriplegia, also experienced a lack of thorough explanation regarding the arbitration agreement. He could not recall the details of the agreement when he signed it and stated that if it had been explained to him more thoroughly, he might have reconsidered signing it. The failure to provide a comprehensive explanation of the arbitration agreement to these residents highlights a deficiency in the facility's admission process.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged resident abuse within the required two-hour timeframe for four residents. An incident involving two residents was reported to the Nursing Home Administrator (NHA) four days after it occurred, and subsequently reported to the state survey agency later that same day. The NHA acknowledged that staff are expected to report allegations of abuse immediately, but this did not occur in this instance. Another incident of alleged resident-to-resident abuse was reported to the NHA shortly after it occurred, but the state survey agency was not notified within the two-hour timeframe due to the NHA's lack of internet access at the time. The facility's policy requires immediate investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a delay in reporting to the appropriate authorities.
Failure to Monitor and Treat Residents' Conditions
Penalty
Summary
The facility failed to identify, assess, properly monitor, and treat mental and/or physical changes in condition for two residents, resulting in severe outcomes. Resident #85, who had severe cognitive impairment and multiple diagnoses including dementia and anxiety, experienced a significant decline in mental and physical health. Despite documented concerns about her condition, including lethargy, refusal to eat, and altered mental status, the facility did not take timely and appropriate actions. Vital signs were not regularly monitored, and necessary risk versus benefit assessments for medications were not completed. This led to Resident #85 being admitted to the ICU in critical condition with severe sepsis, acute metabolic encephalopathy, and other life-threatening conditions. The Director of Nursing acknowledged the failures in monitoring and documentation, and the Physician Assistant responsible for the late entries was no longer employed at the facility due to these issues. Resident #76, who was cognitively intact and had a history of cellulitis, experienced a fever that was not adequately monitored or treated. Despite a physician's order to alternate Tylenol and Ibuprofen and to dip urine for testing, these orders were not promptly followed. The resident's temperature was not consistently recorded, and there was no documentation of the physician being notified about the resident's refusal to provide a urine sample. This lack of monitoring and timely treatment led to a delay in addressing the resident's condition, which was later diagnosed as cellulitis requiring antibiotic treatment. Additionally, the facility failed to ensure coordination of hospice services for one resident, complete wound treatments as ordered for another, and maintain a functioning air mattress for a third resident. The hospice notes were missing from the medical record, which hindered proper care planning. Wound treatments for one resident were frequently missed, and the monitoring of IV antibiotic treatment was not consistently documented. Another resident's air mattress was not functioning properly, and there were no clear instructions for its settings in the care plan. These deficiencies indicate a pattern of inadequate care and documentation, leading to potential harm and unmet care needs for the residents involved.
Failure to Ensure Dignified Dining Experience and Proper Hand Hygiene
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during lunch meal service. Certified Nurse's Aide (CNA) D was seen standing over three residents while assisting them with their meals, moving between them without practicing proper hand hygiene. One resident, R70, who was dependent on staff for eating, struggled to drink from a straw and was left unattended for several minutes. This resident also expressed a need to use the bathroom during the meal. Another CNA, E, was observed assisting multiple residents in a similar manner, without practicing hand hygiene between residents. South CCC F also failed to practice hand hygiene while assisting residents during the meal service. Resident R29, who had multiple diagnoses including Cerebral Palsy and Dysphagia, was observed being assisted by CNA E and South CCC F while they stood over him. R29 was repeatedly instructed to put his chin down while being assisted. Additionally, CNA Q was observed sitting next to R29 and another resident, focused on her phone, and only intermittently assisting R29 with his meal despite the resident's coughing and difficulty clearing his throat. Resident R82, who had severe cognitive impairment and a history of falls, was observed sitting at a dining room table for an extended period without being served his meal. He watched other residents eat for approximately 20 minutes before his meal was brought to him after a Regional Nurse Consultant intervened. The Director of Nursing (DON) acknowledged awareness of the hand hygiene concerns during lunch and mentioned that staff were being re-educated on proper practices.
Failure to Provide Meaningful Activities to Memory Care Residents
Penalty
Summary
The facility failed to ensure meaningful activities were provided to a resident with severe cognitive impairment and all residents in the S-1 and S-2 memory care units. The resident, who has diagnoses including dementia, anxiety, and major depressive disorder, was observed sitting unengaged in the dining room on multiple occasions. The resident's care plan included activities that exceeded their capabilities, and there was no documentation of the resident being offered or participating in group or one-on-one activities in the previous thirty days. The facility's memory care units, housing 52 residents, were observed to have residents unengaged in any activities or diversions. The activities staff was observed playing a card game with a few residents, while others were left unengaged. The activities calendar showed limited scheduled activities, with no activities on weekends or evenings, and some activities were only performed outside the memory care units, making it difficult for memory care residents to participate. Interviews with the Activities Director and a Registered Nurse revealed that staffing cuts had significantly impacted the ability to provide meaningful activities to residents. The Activities Director reported being left with only one assistant for the entire facility, making it challenging to keep residents engaged. The Registered Nurse confirmed that the activities staff was instrumental in keeping residents engaged before the staffing cuts, but the current staffing levels made it difficult to provide the same level of attention and engagement.
Failure to Prevent Repeated Falls for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to prevent repeated falls for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with Parkinson's disease and dementia, experienced multiple falls over a 60-day period. Despite the resident's need for assistance with mobility, transferring, and toileting, as indicated by physical therapy evaluations, the facility did not consistently provide the required support. This resulted in the resident sustaining minor injuries from falls on several occasions. The resident's care plan was not promptly updated to reflect the necessary interventions recommended by physical therapy. For instance, the care plan was only revised two months after the initial evaluation. The facility's fall investigation reports revealed that the resident fell multiple times due to attempting to self-ambulate, unassisted transfers, and poor safety awareness. Interventions such as placing non-slip strips, conducting medication reviews, and using sensor mats were implemented, but the resident continued to fall. The Director of Nursing acknowledged that the resident required assistance at all times with mobility and transfers, yet the facility failed to ensure this level of care was consistently provided. The resident's severe cognitive impairment further complicated the situation, as they were unable to learn or retain new tasks or skills. The facility's failure to implement appropriate safety precautions and provide adequate supervision led to repeated falls and injuries for the resident.
Confidentiality and Documentation Failures
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for one resident and maintain complete, accurate, and timely medical records for three residents. During an observation, a computer screen on a medication cart was left open, displaying a resident's electronic Medication Administration Record (e-MAR) with personal and health information visible. The responsible RN acknowledged the mistake but did not fully understand the severity of the breach in confidentiality. Another RN confirmed the proper protocol of logging off and closing the computer screen to protect resident information, which was not followed in this instance. For another resident, the facility failed to accurately document the guardian's name on a Risk vs. Benefit/GDR Form. The form listed an incorrect name, and neither the Nursing Home Administrator (NHA) nor the Director of Nursing (DON) could identify the person listed. The DON later admitted it was a typo, but the error remained uncorrected, leading to inaccurate medical records. Additionally, the facility did not obtain a proper signature from a guardian on a Medical Treatment Decision Form for another resident. The form noted a verbal confirmation via phone but lacked the guardian's name and signature, which are required for legal documentation. Furthermore, a resident's medical records contained late entries by a Physician Assistant (PA), which were not documented until three days after the resident was admitted to the hospital. This delay in documentation meant critical health information was not available to other medical providers and staff, potentially impacting the resident's care and leading to hospitalization.
Failure to Maintain Effective QAPI Committee and Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified care concerns, responded to deficiencies, and maintained compliance for all residents. This resulted in repeated deficiencies from the previous annual survey and undesired outcomes for residents. Specifically, the facility was found to be out of compliance with F-679, which pertains to meeting the activity needs and interests of residents. Surveyors observed residents in the memory care unit with no meaningful engagement, and the activities calendar showed no programming on weekends. Records for two residents did not reflect routine documentation for group or one-on-one activities. The Director of Nursing (DON) acknowledged the issue but stated that the QAPI committee felt it was meeting regulatory expectations and had no performance improvement plans in place to address the concern identified by the surveyors. Additionally, the facility was found to be out of compliance with F-684, which concerns quality of care issues such as identifying significant weight loss, ensuring nutritional needs are met, and assessing, monitoring, and reporting changes to the physician. During the annual survey, surveyors found evidence of quality of care concerns for multiple residents, including a resident whose change in condition was not identified, resulting in hospitalization, and another resident who had a fever reported to the physician but was not continuously monitored for infection. Other issues included a resident with an air mattress for impaired skin that was not operating as ordered, lack of coordination of care with hospice for another resident, and a significant weight loss in another resident that was not assessed or monitored. The DON was made aware of these findings but stated that the QAPI committee was not aware of the repeated deficient practices.
Inadequate Ventilation in North Hall
Penalty
Summary
The facility failed to maintain adequate ventilation, resulting in stagnant, humid air and unpleasant odors in the North Hall. On 4/1/24, observations revealed that the exhaust vents in the shower room and bathrooms of two resident rooms were not functioning, as evidenced by the lack of suction when tested with a paper towel. During an interview, the Maintenance Director stated that the ventilation system is inspected twice a year and that the North halls have a separate rooftop unit from the South Halls.
Failure to Ensure Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure Certified Nurse Aides (CNAs) completed a minimum of twelve hours of in-service training annually. During the survey, it was found that CNA D had only 5.25 hours of training, including abuse training, but had not completed dementia training. CNA E, hired on 6/5/23, had no record of in-service hours or abuse training. CNA Q had only 1 hour of in-service training, with no abuse training listed and dementia training initiated only after the survey began. CNA X had 2 hours of training, with no abuse training listed and dementia training completed after the survey began. The Director of Nursing (DON) indicated that Human Resources tracks employee in-service training and confirmed that the provided information was all that was available.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from the responsible parties of two residents before administering psychotropic medications. Resident 70, who had multiple diagnoses including depression, anxiety, and alcohol-induced persisting dementia, was administered Zyprexa without the knowledge of his legal guardian. The facility's records showed that an incorrect name was listed as the person informed about the medication, and there was no evidence that the guardian was aware of the medication's administration, indications, or risks and benefits until much later. The Director of Nursing acknowledged the error and stated it was a typo, but the facility could not provide adequate documentation to confirm that the guardian had been properly informed in a timely manner. Similarly, Resident 87, who had diagnoses including depression, dementia with psychotic disturbance, and visual hallucinations, was administered Lorazepam without the knowledge of his Durable Power of Attorney (DPOA). The facility's records did not show any indication that the DPOA was informed about the medication's risks, benefits, or reasons for use before it was administered. It was only 26 days after the administration of Lorazepam that the DPOA was documented as being informed. Interviews with the Nursing Home Administrator and the Director of Nursing revealed that they were unaware of the errors in the documentation and the failure to inform the responsible parties. The facility's attempts to rectify the situation included sending emails to the guardians, but these communications lacked proper documentation and timestamps, making it unclear whether the responsible parties were adequately informed in a timely manner.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident #44, resulting in potential safety hazards and compromised care. Resident #44, who has diagnoses including bipolar disorder, heart disease, chronic obstructive pulmonary disease (COPD), and dependence on oxygen, was observed in a cluttered room with personal possessions piled on the floor, obstructing access to the bed and oxygen concentrator. The resident indicated that she had not been offered extra storage or shelves to organize her belongings. The clutter in the room posed a significant risk for falls and made it difficult to access the oxygen concentrator, which was necessary for the resident's respiratory condition. During a follow-up observation, the Nurse Manager confirmed the safety concerns related to the clutter and the inaccessibility of the oxygen concentrator. The resident's care plans indicated a potential for hoarding and clutter, with interventions such as staff offering to clean the room weekly and reducing fall risks by cleaning up spills and clutter. However, there was no documentation that these interventions were consistently attempted, and the clutter remained, making it impossible to visualize a marked spot for the resident's walker. The facility's failure to maintain a clean and safe environment for Resident #44 directly contributed to the deficiency noted in the report.
Failure to Revise and Implement Care Plans
Penalty
Summary
The facility failed to revise the care plan to meet identified care concerns for two residents and failed to implement revisions to the plan of care for one resident. Resident #82, who has severe cognitive impairment and a history of falls, was not provided the necessary assistance as recommended by a physical therapy evaluation. Despite recommendations for one assist with mobility and transfers due to poor safety awareness, the care plan was not updated until two months later, during which time the resident experienced multiple falls and minor injuries. Resident #101, who is cognitively intact, experienced significant weight loss and edema. Despite a 9.4 lbs weight loss over ten days and the administration of a diuretic for edema, the care plan was not updated to reflect these changes. The registered dietitian did not reweigh the resident to check the effectiveness of the diuretic, and the care plan did not address the issue of edema or its management. Resident #70, who has severe cognitive decision-making skills and is dependent on staff for assistance with eating, was not provided the necessary adaptive equipment and one-to-one assistance as required. During meal observations, the resident struggled to eat and drink independently, and the care plan was not updated to reflect the need for adaptive equipment and one-to-one assistance. Additionally, the CNAs assisting the resident were not familiar with the resident's needs, further compromising the resident's care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered per standards of practice for three residents. For Resident #60, the nurse allowed the resident's husband to administer medications without staying in the room, and there was no assessment to confirm the husband's ability to assist with medication administration. The resident had severe cognitive loss and needed assistance with all care, making the nurse's presence crucial during medication administration. The nurse manager confirmed that the nurse should have stayed in the room and acknowledged the lack of a process for the resident's husband to give medications. For Resident #93, the nurse initiated a breathing treatment and left the room, leaving the resident unattended. The resident had full cognitive abilities but required assistance with all care. The nurse manager confirmed that the nurse should have remained in the room during the breathing treatment and stayed until it was completed. For Resident #405, the nurse administered an IV antibiotic outside of the physician-prescribed orders. The antibiotic was ordered to be given every 12 hours, but the nurse administered it at inconsistent times, interpreting the order as allowing a window between 0700-1000. The Director of Nursing confirmed that the antibiotic should be given every 12 hours as per the physician's order and not within a flexible time window. The facility's standard medication administration times were also reviewed and found to be inconsistent with the physician's order.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services for Resident #60, who had a history of stroke, brain and ovarian cancer, Alzheimer's Dementia, heart disease, falls with vertebral fracture, anxiety, depression, diabetes, and lymphedema. The resident was observed with severe cognitive loss and required assistance with all care. Despite the resident's need for range of motion (ROM) exercises, there was no evidence of such services being provided. The resident's care plan and physician orders did not include any mention of ROM exercises or maintenance services, and the Director of Nursing (DON) confirmed that the facility did not have a restorative nursing program in place. Instead, the facility relied on nurse aides to provide maintenance ROM, but this was not documented or observed for Resident #60. During interviews, it was revealed that the facility did not have a restorative nurse or restorative nurse aides, and the nurse aides were responsible for providing maintenance ROM. However, the care plan for Resident #60 did not mention any ROM exercises or maintenance services, and the resident was not receiving these services. The facility's policy on restorative nursing programs stated that all residents should receive maintenance restorative nursing services, but this was not being implemented for Resident #60. The lack of restorative nursing services resulted in the potential for a decline in the resident's condition.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor weight changes for a resident, resulting in significant weight loss. The resident, who was admitted with diagnoses including acute gastric ulcer, kidney disease, and a blood clot in the right leg, experienced a weight loss of 9.4 lbs (5.72%) over ten days. Despite the resident's care plan indicating a goal to maintain nutritional status, the weight loss was not addressed in a timely manner. The resident was given a diuretic for edema, but no follow-up weight monitoring was conducted to assess the effectiveness of the treatment or to ensure accurate weight tracking. The Registered Dietitian (RD) overseeing weight changes did not reweigh the resident after the diuretic treatment and dismissed the weight loss warning based on an unverified hospital weight record. The care conference notes and weight change notes did not reflect the significant weight loss or any changes in care planning regarding nutrition, hydration, edema, or weight monitoring. This lack of proper assessment and monitoring led to the resident sustaining a significant weight loss without appropriate intervention.
Failure to Follow PICC Line Dressing Change Protocols
Penalty
Summary
The facility failed to follow accepted standards of practice for a peripherally inserted central catheter (PICC line) dressing change for a resident, resulting in improper hand hygiene, lack of use of a sterile barrier, and failure to measure the external catheter length. The resident, who had multiple health issues including meningitis, brain abscess, brain and lung cancer, diabetes, chronic kidney disease, and a history of pulmonary embolism, was observed with an IV running via an electronic pump. The IV dressing on the resident's right upper arm was dated 3/27/2024, and the IV bag contained Ceftriaxone, an antibiotic. During the dressing change, the nurse did not use the sterile barrier provided in the PICC line dressing change kit, did not perform hand hygiene after removing the old dressing and before applying sterile gloves, and did not measure the central line length or arm circumference as required by the physician's orders. The facility's policy on central venous catheter dressing changes, revised in July 2016, specifies that hand hygiene should be performed, a sterile barrier should be used, and the catheter insertion site should be cleaned with an approved antiseptic solution. The policy also requires measuring the external catheter length on admission, with each dressing change, and as needed. During an interview, nurse managers confirmed that the nurse should have washed her hands between gloves and used a sterile barrier. The failure to adhere to these protocols could result in complications, including infection and migration of the catheter, although these potential consequences were not directly stated in the report.
Failure to Ensure Unobstructed Access and Proper Humidification for Oxygen Concentrator
Penalty
Summary
The facility failed to ensure unobstructed access to an oxygen concentrator and provide oxygen humidification for a resident, resulting in the potential for inadequate oxygen delivery and discomfort. Resident #44, who has diagnoses including COPD and chronic respiratory failure, was observed with a nasal cannula but without visible oxygen equipment due to clutter in the room. The oxygen concentrator was found behind personal belongings, making it inaccessible from the resident's bedside. The resident reported that the humidification bottle had been empty, causing dryness in her nose, and a nurse had to bring a new humidification container during the observation. Further observations revealed that the humidification bottle was not properly maintained, with a date discrepancy indicating it had not been changed as reported. The physician's orders and care plans did not include instructions for ensuring humidification or maintaining unobstructed access to the concentrator. This oversight led to the resident experiencing discomfort and potential respiratory distress due to inadequate oxygen humidification and access issues.
Failure to Document and Act on Resident's Declining Condition
Penalty
Summary
The facility failed to timely document assessments and findings in the medical record by a medical provider and did not ensure necessary monitoring, care, and medical treatment when changes in condition were noted for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including Pseudobulbar Affect, Bipolar Disorder, Dementia, and Anxiety, was admitted to the facility and later experienced a significant decline in health. Despite observable changes in the resident's condition, such as increased weakness, decreased mental status, and refusal to eat, the medical provider did not act upon these changes in a timely manner. The resident's electronic medical record (EMR) showed that vital signs were only obtained twice between 2/7/24 and 2/23/24. The Physician's Assistant (PA) made several late entries into the medical record, documenting observations and changes in the resident's condition that were not available for other healthcare providers or the supervising physician to review in real-time. The PA also made medication changes without ordering additional monitoring or lab work, despite the resident's deteriorating condition. On 2/23/24, the resident was transported to the hospital with severe symptoms including high fever, high heart rate, and altered mental status. The hospital diagnosed the resident with severe sepsis, acute metabolic encephalopathy, hypernatremia, acute cystitis with hematuria, and acute kidney injury. The hospital's social work consult raised concerns about potential neglect, as the resident appeared to have been in a minimally responsive state for a week. The facility's Director of Nursing (DON) acknowledged that increased monitoring should have been ordered and that the PA's documentation and actions were inadequate.
Failure to Provide Updated Guardianship Documentation
Penalty
Summary
The facility failed to provide medically-related social services for a resident (R98), resulting in the resident not having current up-to-date guardianship documentation. R98, a [AGE] year-old resident with multiple diagnoses including brain cancer, cerebral edema, convulsions, delusional disorder, pulmonary embolism, and aphasia, was admitted to the facility with Guardian K as the primary contact for healthcare needs. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. The temporary guardianship order for Guardian K had expired, and there was no updated guardianship documentation in the resident's medical record. The medical record did not contain documentation from two physicians or a physician and a psychologist determining that R98 could no longer make medical decisions. Additionally, there was no evidence that the resident's mental capacity had changed since the temporary guardianship order. Therefore, Guardian K could not legally make medical decisions for R98 without a valid guardianship order. The Nursing Home Administrator confirmed that the expired temporary guardianship order was the most current documentation available in the resident's medical record.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to properly monitor for psychotropic medication side effects and failed to identify and report signs resulting from medication changes for one resident. The resident, who had diagnoses including Pseudobulbar Affect, Manic Depression, Dementia, and Anxiety, was admitted to the facility and later experienced severe cognitive impairment. The resident was transported to the hospital with altered mental status and functional decline, where it was noted that the resident had a high fever, high heart rate, and was minimally responsive. The hospital suspected polypharmacy, Serotonin Syndrome, or Neuroleptic Malignant Syndrome as potential causes of the resident's condition. The facility's records revealed that the resident had been prescribed multiple medications, including Zyprexa, clonazepam, and lorazepam, without proper documentation of the Risk versus Benefit analysis for these medications. The Social Worker responsible for initiating the Risk and Benefit forms admitted to missing the orders for lorazepam and clonazepam. Additionally, the resident exhibited signs of excessive sedation, lethargy, and refusal to eat, which were documented in the facility's records but not acted upon by the nursing staff. The Director of Nursing acknowledged that increased monitoring should have been ordered and that the abnormal observations should have been addressed. The Medication Administration Record for the resident showed that staff documented no abnormal findings despite clear indications of adverse side effects. The lack of proper monitoring and failure to act on documented concerns led to the resident being admitted to the hospital in critical condition. The facility did not provide further documentation or information before the survey exit.
Failure to Publicly Post Nurse Staffing Data
Penalty
Summary
The facility failed to publicly post nurse staffing data as required. On 4/8/24 at 11:20 AM, a review of the facility's posting was conducted, and the staff posting could not be located. At 11:30 AM, the Unit Manager (UM) was asked about the location of the daily staff posting data. The UM took the surveyor to the main Nurses Station where a binder titled the facility's Schedule Book was found. Inside the book, along with the staff schedule, was the completed daily staff posting form for 4/8/24. When asked if this information was posted in the facility, the UM stated No and indicated that the daily staff posting is kept in the Schedule Book. The book cover did not reflect that the daily staff posting was inside the binder or that public information was contained within.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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