Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Springs, Michigan.
- Location
- 400 Jeffrey, Cedar Springs, Michigan 49319
- CMS Provider Number
- 235294
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with a central venous port and dependence on renal dialysis was placed on enhanced barrier precautions (EBP) per physician order and care plan, requiring PPE use during high-contact care such as hygiene and repositioning. During care, a CNA scratched the resident’s bare back and repositioned her in bed without wearing gloves or a gown, despite acknowledging awareness of the EBP requirement, and the ICP confirmed PPE should have been used. Separately, the Maintenance Director reported the water management plan was still in progress, with no active disinfection sampling and only intermittent flushing of some fixtures. Surveyors observed unflushed fixtures, including a hopper, hose sprayer, and over-hopper sink that produced brown, discolored water when turned on, as well as capped water lines in a shower room that had not been flushed or removed, despite facility policies calling for defined control measures, testing protocols, and monthly disinfectant residual testing.
A resident experienced mental anguish and fear due to another resident's aggressive and inappropriate behavior, which the facility failed to adequately address. Despite staff observations and reports, the administration did not conduct a thorough investigation or implement sufficient protective measures, resulting in a deficiency in ensuring a safe environment.
A resident with a history of falls and severe cognitive impairment fell and sustained injuries due to inadequate supervision in an LTC facility. The resident required maximal assistance and was placed in a room far from the nurses' station, limiting staff's ability to monitor him closely. Despite known risks and family warnings, the facility did not provide sufficient supervision, resulting in the resident's fall and injury.
A facility failed to notify a resident's family member and DPOA of changes in the resident's condition, including an open area on the ankle and localized edema. The family member only learned of these issues by asking the nurse during a visit, despite the facility's policy to inform the DPOA of acute health changes.
The facility failed to follow its abuse policy for three residents, leading to unreported and uninvestigated incidents of resident-to-resident abuse. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress. Staff intervened but did not report the incidents immediately, and the NHA did not conduct an investigation. Additionally, concerns about potential sexual abuse involving another resident were not investigated or reported to the state agency.
The facility failed to report allegations of abuse involving three residents to the State Agency in a timely manner. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress, but the incidents were not reported as required. Additionally, an allegation of potential sexual abuse involving a severely cognitively impaired resident was not reported or investigated. The facility's staff, including the NHA and DON, did not follow the policy for reporting and investigating abuse allegations.
The facility failed to investigate allegations of abuse involving three residents, including aggressive behavior by a resident with dementia and potential sexual abuse concerns. Despite staff intervention and reports, the incidents were not thoroughly investigated, and the state agency was not notified, violating the facility's policy on abuse, neglect, and exploitation.
A facility failed to refer a resident for a Level II PASARR evaluation despite the resident exhibiting significant mental health issues, including verbal and sexual behaviors, and receiving antipsychotic medication. The resident's care plan addressed these behaviors, but no referral was made to the state mental health authority, as confirmed by interviews with the LMSW and DON.
A resident's aggressive behavior towards another resident was not documented by an LPN, despite being witnessed during two separate incidents. The LPN reported the incident to the NHA, who advised against documentation due to concerns about transfer referrals. This lack of documentation left the PA unaware of the incidents, hindering the evaluation and management of the resident's behavior.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite interventions in place, inadequate staffing levels during meals allowed the incident to occur without immediate intervention, resulting in the resident being unable to protect herself.
The facility failed to maintain a safe and sanitary environment, with issues such as raw wood shelving for clean supplies, deteriorating storage areas, and stained privacy curtains. A resident with COPD had a dusty fan, soiled curtain, and dusty windowsill, despite cleaning protocols. Housekeepers acknowledged the oversight, but deficiencies persisted.
The facility failed to provide palatable and appropriately heated food to several residents, leading to dissatisfaction and potential nutritional decline. Residents reported cold meals, unappetizing food, and inadequate seasoning, with meal trays transported in non-insulated carts. This issue affected residents with various health conditions, including stroke, diabetes, and dysphagia, highlighting a significant deficiency in meal service.
The facility did not ensure an effective training program for abuse prevention, leading to potential resident safety risks. The DON reported the absence of a staff development role and that she monitored online training completion. The facility lacked an on-site HR employee, with records kept at the corporate level. A former administrator noted annual online abuse education, last completed in the summer. A review showed 11 out of 66 employees had not started the required module, and the DON and a Unit Manager were still in progress. The facility failed to provide documentation of completed abuse training for all employees.
The facility failed to ensure timely meal service and call light response, affecting residents' dignity and care. Observations showed inconsistent meal service, with some residents waiting longer than others, contrary to the expected practice of serving one table at a time. A resident with Alzheimer's and another cognitively intact resident expressed dissatisfaction with the meal service order. Additionally, a resident reported long call light wait times, sometimes up to an hour, despite the facility's standard of a 3-minute response time.
A facility failed to update a care plan for a resident after a new diagnosis of dementia. The resident, who was cognitively intact, was diagnosed with dementia, but the care plan did not reflect this change. The Unit Manager confirmed the oversight during an interview.
A facility failed to consistently apply a brace for a resident with limited ROM, potentially leading to decreased ROM and contractures. The resident, with a history of stroke and paralysis, had a care plan requiring PROM exercises and a brace application, but observations showed the brace was often not used or improperly applied. The Rehab Director had to intervene to adjust the brace and perform ROM exercises, highlighting a lapse in following the facility's restorative nursing policy.
The facility failed to ensure proper PPE usage during a COVID-19 outbreak, with staff observed not wearing required masks and eye protection. A resident with COVID-19 was under droplet/contact precautions, but staff did not adhere to PPE requirements. Another resident on Enhanced Barrier Precautions due to a pressure ulcer received care without staff donning gowns, indicating a lack of awareness of EBP protocols.
A resident with multiple health conditions experienced issues with the call light system, which was not within reach and malfunctioned, leading to delayed staff response. The facility provided a doorbell pendant as an alternative, but it was ineffective due to its single ding and potential confusion with the front doorbell. Staff interviews and observations confirmed ongoing issues with the call light system, attributed to electrical problems within the wall.
The facility failed to protect residents from sexual abuse, involving three residents with cognitive impairments. A resident was found with another resident's hand up her shorts, and two other residents engaged in inappropriate sexual interactions despite guardians' consent for limited contact. Staff were unclear about boundaries, leading to multiple incidents of inappropriate contact. The facility's policies failed to prevent these incidents, resulting in a deficiency.
A cognitively impaired resident was allegedly abused by another resident in a LTC facility. The incident was witnessed by a CNA, who intervened and reported it. The facility's response included 15-minute checks and moving the victim, but staff reported these measures were insufficient, especially during short staffing. The facility did not conduct a thorough investigation or implement adequate interventions, leading to further abuse allegations.
The facility failed to maintain accurate medical records for two residents with cognitive impairments, leading to incomplete documentation of observed sexual interactions. Staff, including CNAs and an RN-UM, witnessed these interactions but did not document them in the EHR, believing existing care plans sufficed. A Social Services Manager also failed to document a conversation with a guardian about consent boundaries. This lack of documentation could impact the facility's ability to provide appropriate care.
Failure to Implement Enhanced Barrier Precautions and Maintain Water Management Controls
Penalty
Summary
The deficiency involves failure to properly implement enhanced barrier precautions (EBP) for a resident and failure to maintain an active, ongoing water management program to reduce the risk of Legionella and other opportunistic premise plumbing pathogens. A female resident with dependence on renal dialysis and a central venous port was under physician orders and care plan directives for EBP during high-contact care activities, including dressing, bathing, transferring, hygiene, linen changes, toileting/brief changes, and device or wound care. During observation, a CNA was seen scratching and rubbing the resident’s bare back and then repositioning her in bed without wearing gloves or a gown, despite acknowledging that the resident was on EBP and that PPE should have been used for this type of care. The Infection Control Preventionist confirmed that the resident was on EBP due to the central line and that PPE was required during such high-contact care activities. The deficiency also includes lack of a fully implemented water management program consistent with the facility’s own policy. The Maintenance Director reported that the water management plan was still a work in progress and that there were no established control measures and control limits in active use to reduce the risk of Legionella or OPPP, including no current sampling for disinfection levels. He stated that he maintained ice machines, cleaned the fountain in the summer, and flushed some taps every few days, but had not been flushing certain fixtures. Observation of a soiled utility room revealed a hopper with an attached hose sprayer and an over-hopper sink that had not been fully flushed; when the water was turned on, brown and discolored water came from both hot and cold lines and the sprayer. In a shower room, capped water lines extended several feet from the main water line and had not been flushed or removed. Review of the facility’s written Water Management Program and related documents showed that control measures, testing protocols, and control limits, including monthly disinfectant residual testing of hand sinks, showers, and whirlpool baths, were required but not being carried out as described.
Failure to Protect Resident from Mental and Psychosocial Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and psychosocial abuse, specifically involving resident-to-resident interactions. Resident #106, who was cognitively intact with a BIMS score of 15/15, experienced mental anguish and fear due to the behavior of Resident #105. Resident #105, who also had a BIMS score of 15/15, exhibited behaviors such as staring, aggressive verbal interactions, and inappropriate sexual conduct, which were not adequately addressed by the facility. Staff members, including a registered nurse, a certified nursing assistant, and a licensed practical nurse, observed and reported Resident #105's behavior towards Resident #106. Despite these observations and reports, the facility's administration, including the Nursing Home Administrator, did not conduct a thorough investigation or implement sufficient measures to protect Resident #106. The facility's inaction led to Resident #106 feeling unsafe and fearful, impacting her ability to move freely within the facility. The facility's policies on abuse prevention and response were not effectively implemented, as evidenced by the lack of immediate action following the incidents. The Interdisciplinary Team discussed potential interventions, such as increased supervision and door alarms, but these were not promptly executed. The failure to address Resident #105's behavior and protect Resident #106 from mental and psychosocial abuse constitutes a deficiency in the facility's duty to ensure a safe environment for all residents.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and required maximal assistance to stand and transfer, was admitted with diagnoses including unsteadiness on feet and repeated falls. Despite these known risks, the resident was placed in a room far from the common areas and nurses' station, limiting the ability of staff to provide close supervision. On the night of the incident, the staffing on the resident's hall was limited to one nurse and one CNA for 21 residents, which was insufficient to meet the resident's needs for close supervision. The resident was found on the floor after an unwitnessed fall, having sustained a fracture to the right humerus and thoracic vertebrae. Prior to the fall, the resident exhibited increased agitation, poor safety awareness, and attempted to transfer without assistance, indicating a need for more frequent monitoring than was provided. Interviews with staff and family members revealed that the resident was known to be confused and restless, particularly at night, and required immediate response to his needs. Despite this, the facility did not implement additional measures to ensure the resident's safety, such as increased supervision or frequent checks, leading to the fall and subsequent injury.
Plan Of Correction
Element 1: Resident #100 no longer resides at the facility. Element 2: All residents have the potential to be affected by this deficient practice. A 100% audit of current residents with falls in the last 30 days was completed on 3/24/25 to ensure residents' current needs, have appropriate notification and care plans were updated as needed. Element 3: NHA and DON reviewed the Fall prevention policy on 3/17/25 and deemed it appropriate. The DON/designee will re-educate all licensed nurses on fall prevention policy prior to 3/24/2025. Any licensed nurses not re-educated by 3/24/25 will not work until re-education is completed. An Ad-Hoc QAPI meeting will be held on 3/20/25 to review fall reduction policies and the plan of correction. Medical Director reviewed. Element 4: DON/Designee will review newly admitted residents and residents with falls weekly during clinical meetings for three (3) months to ensure interventions were implemented and appropriate, and notifications completed. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. DON is responsible for achieving and sustaining compliance.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in care or condition for one of the residents reviewed for notification of change. This deficiency involved a resident with a history of Huntington's disease, dementia, and adult failure to thrive, who was found to have an open area on the right ankle and was diagnosed with localized edema. Despite these changes in the resident's condition, the family member and Durable Power of Attorney (DPOA) reported not being informed by the facility since the resident's admission. The family member expressed frustration over the lack of communication, stating that she only became aware of the resident's new health issues when she inquired with the resident's nurse during a visit to the facility. The Director of Nursing confirmed that it is the facility's policy to inform a resident's DPOA of any acute changes in health, which was not adhered to in this case.
Plan Of Correction
Element 1: Resident #102 resides in the facility and has a FM / DPOA who was notified of resident's condition on 3/17/2025. Element 2: All residents reviewed in Clinical stand-up meeting on 3/19/25 to identify any change of condition in real time. DPOA notified of any changes identified. Element 3: All Nursing staff will be re-educated by the QAPI Development Coordinator on the Change in Condition policy by 3/24/2025. Any staff member that has not been re-educated by 3/24/2025 will be removed from the schedule until re-education is completed. Element 4: DON / designee will review the clinical dashboard daily, Monday-Friday to identify changes of condition and ensure notifications are completed appropriately. The Director of Nursing is responsible for achieving and maintaining compliance.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for three residents, resulting in staff not reporting resident-to-resident observations of abuse to the Nursing Home Administrator (NHA) immediately, the facility not initiating a thorough investigation, and the facility not reporting allegations of abuse to the state agency. This deficiency involved Resident #105, who had a history of inappropriate physical touching and aggressive verbal behaviors, and Resident #106, who was the target of Resident #105's aggressive actions. Despite staff interventions during incidents where Resident #105 approached Resident #106 aggressively, the incidents were not reported immediately, and no investigation was initiated. Resident #105, who was cognitively intact, exhibited aggressive verbal behaviors towards Resident #106, causing fear and distress. Staff members, including an LPN and a Physical Therapy Assistant, witnessed these incidents and intervened to redirect Resident #105. However, the incidents were not documented or reported to the NHA immediately. The NHA did not conduct an abuse investigation, believing the staff's reactions were overly reactive and that Resident #106 was not significantly affected. This inaction led to a failure in addressing the potential abuse and ensuring the safety of Resident #106. Additionally, concerns were raised about potential sexual abuse involving Resident #107, who was severely cognitively impaired. A family member reported these concerns to a Unit Manager, but the facility did not investigate further or report the allegations to the state agency. The Director of Nursing confirmed that the facility's abuse policy was not followed, as there were no obvious signs of injury, and the resident stated they felt safe. This lack of action and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for additional allegations to go unreported and delayed investigation. Resident #105, who has a history of inappropriate physical behavior and aggressive tendencies, was involved in two incidents with Resident #106. During these incidents, Resident #105 approached Resident #106 aggressively, causing fear and distress. Despite staff intervention, the incidents were not reported immediately as required by the facility's policy. Resident #106, who was the victim of Resident #105's aggressive behavior, reported feeling scared and harassed. The facility's Unit Manager and Nursing Home Administrator were aware of the incidents but did not conduct an abuse investigation or report the incidents to the state agency. The Nursing Home Administrator believed that staff were overreacting to Resident #105's behavior and did not consider the incidents as abuse. Additionally, there was an allegation of potential sexual abuse involving Resident #107, who is severely cognitively impaired. A family member reported concerns about a male staff member to the Unit Manager, but the facility did not report the allegation to the state agency or conduct a further investigation. The Director of Nursing confirmed that the facility did not report the allegation, which was a violation of the facility's policy to protect residents and report all alleged violations immediately.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving three residents, leading to a potential risk of further abuse. Resident #105, who had diagnoses including depression, paraphilia, unspecified dementia with psychotic disturbance, and anxiety, was involved in an incident with Resident #106. Resident #106 reported feeling harassed and fearful after Resident #105 approached her aggressively on two occasions, despite staff intervention. LPN H, who witnessed the incidents, did not report them immediately but later informed the Nursing Home Administrator (NHA) A, who decided against documenting the incident to avoid affecting admission referrals for Resident #105. Additionally, a family member of Resident #107's roommate reported concerns of potential sexual abuse by a male staff member. Unit Manager (UM) E was informed of these concerns but did not conduct a full investigation, as it was determined there was no immediate concern due to limited male staff presence. The Director of Nursing (DON) B confirmed that a full investigation was not completed for the sexual abuse concerns involving Resident #107. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of all alleged violations to the facility administrator and state agency. However, in these cases, the facility did not adhere to its policy, as the allegations were not thoroughly investigated, and the state agency was not notified. This failure to act according to policy resulted in a deficiency citation for the facility.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/25 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a referral was made for a Level II PASARR evaluation for a resident who exhibited significant mental health issues. The resident, who was admitted with diagnoses of depression and anxiety, was cognitively intact but displayed verbal behaviors such as threatening, screaming, and cursing at others. The resident was also receiving antipsychotic medication. Despite these behaviors and the initiation of antipsychotic medication, the facility did not refer the resident for a Level II PASARR evaluation, which is required when a resident exhibits a newly evident or possible serious mental disorder. The resident's care plan included interventions for inappropriate physical and verbal behaviors, and the resident was diagnosed with paraphilia. A behavioral health provider noted episodes of sexual behaviors, auditory hallucinations, and delusional thinking. Despite these significant changes, the facility did not report them to the state mental health authority for a Level II PASARR assessment. Interviews with the Licensed Medical Social Worker and the Director of Nursing confirmed that no referral had been made, indicating a failure to address the resident's psychosocial needs adequately.
Plan Of Correction
Element 1: Resident #105's change in condition was submitted to OBRA on 3/17/25. Element 2: A facility-wide audit was completed by the regional social worker on 3/13/25 to ensure that no significant diagnosis or medications have been changed. Any changes identified were corrected. Element 3: The resident assessment/coordination with PASARR program policy was reviewed by the NHA and deemed appropriate on 3/17/25. The social services director/designee was re-educated regarding the resident assessment/coordination with PASARR program policy on 3/17/25. Element 4: All residents reviewed in daily clinical meeting for any new significant mental illness diagnosis or medications weekly x4 weeks and monthly 3 months. Any diagnosis or medications requiring a Level II assessment will be submitted to OBRA by social services director/designee. The NHA is responsible for achieving and sustaining compliance.
Failure to Document Resident Altercations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the residents reviewed, specifically regarding the documentation of abusive behaviors. On February 26, 2025, Resident #105 was involved in two separate incidents where they aggressively confronted another resident, Resident #106, in the hallway and later in the therapy gym. Despite witnessing these altercations, LPN H did not document the incidents in Resident #105's medical records. LPN H reported the incident to the Nursing Home Administrator (NHA) the following day but was instructed not to document it due to concerns about the impact on Resident #105's transfer referrals. The lack of documentation meant that the Physician's Assistant (PA) responsible for managing Resident #105's behaviors was unaware of the incidents and could not evaluate or adjust interventions accordingly. The Director of Nursing (DON) confirmed that staff are expected to report and document any potential abuse immediately, but this protocol was not followed. The failure to document these incidents resulted in a lack of proper evaluation and monitoring of Resident #105's behaviors, potentially compromising the safety and well-being of other residents.
Plan Of Correction
Element 1: Resident #105 no longer resides at the facility. Resident #106 care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Element 2: All residents have the potential to be affected by this practice. IDT team reviewed 24-hour on 3/19/2025 to review all residents and ensure information was not missing from medical record. Element 3: Clinical staff have been re-educated by the DON/designee on Nursing documentation of healthcare data from Perry and Potter 10th edition pg 51- 53; Legal guidelines for documenting and reporting and recording. to include timely documentation of resident condition variances. Those not receiving the education prior to date of allegation of compliance 3/24/25 will complete the education prior to their next scheduled shift. Element 4: Facility IDT will review the electronic health record during facility daily clinical meeting Monday through Friday with a lookback review done on Monday for any weekend documentation. The DON/designee will follow up on any identified missing or incomplete documentation. Any incomplete documentation will be resolved upon identification. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. The Administrator is responsible for achieving and sustaining compliance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with severe cognitive impairment due to dementia and anxiety, who was unable to effectively communicate or understand situations. This resident was found outside the south cafe door when another male resident, who was cognitively intact, was seen with his hand in her pants. Despite attempts to roll away, the male resident grabbed her hair and pulled her back. Witnesses reported the female resident was crying and appeared helpless during the incident. The male resident had a documented history of inappropriate sexual behavior, including making sexual requests to staff and other residents, exposing himself, and masturbating in public areas. Despite these behaviors, the facility's care plan for him included interventions such as having two staff members present during personal care and informing him that his behavior was inappropriate. However, these measures were insufficient to prevent the incident with the female resident. Staffing levels during the incident were inadequate, with only one CNA and one nurse present on the unit, as the second CNA was assisting in the dining room. This lack of supervision contributed to the male resident's ability to engage in inappropriate behavior without immediate intervention. Interviews with staff and witnesses confirmed that the male resident's behavior was escalating, and the facility's response was insufficient to protect the female resident from harm.
Environmental and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a tour of the central supply storage, raw wood shelving was used for storing clean and sanitary supplies, which were stained, chipped, and pitted. The outside storage barn had openings and rusted areas that could allow pest entry, and the outside storage shed had a deteriorating roof dropping debris onto stored equipment. In the main hall soiled utility room, brown water was discharged from old water lines, and privacy curtains in the west hall spa room were stained. The east hall spa room had a shower chair with crusty debris, and the south hall spa room had a shower chair with a smeared disposable wipe. Additionally, the microwave in the cafe had pitting and scuffing, and brown-tinged water was observed in the south hall soiled utility room. Resident #22, who was cognitively intact and had chronic obstructive pulmonary disease, was found to have a personal fan caked with dust and debris, a soiled privacy curtain, and a dusty windowsill in his room. Despite the facility's cleaning protocol, these issues persisted over multiple days. Housekeepers reported that resident rooms were cleaned daily, including wiping down surfaces and inspecting privacy curtains, but the deficiencies in Resident #22's room were not addressed. The facility's Room Clean / Deep Clean / Discharge Check Off Sheet indicated that staff should clean and dust various areas, but these tasks were not completed in Resident #22's room.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food products to five out of seven residents reviewed for food palatability, resulting in dissatisfaction with meals and the potential for nutritional decline. The Resident Council Minutes from late November and early December 2024 revealed ongoing concerns about cold food and lack of flavor. Interviews with residents confirmed these issues, with reports of cold meals, unappetizing food, and inadequate seasoning. Residents expressed dissatisfaction with the temperature and taste of the food, noting that the meal trays were transported in non-insulated carts, contributing to the problem. Resident #8, who is cognitively intact and has a history of stroke, protein-calorie malnutrition, and diabetes, reported that the food was often cold and unpalatable, with specific complaints about the coffee and certain meals being dry or hard. Resident #9, also cognitively intact, mentioned that the quality of food varied depending on the kitchen staff and that meals were sometimes cold when served in her room. Resident #4, with cognitive communication deficits and other health issues, expressed that her food was unappealing and cold, and the lack of seasoning did not improve the taste. Resident #12, with Parkinson's disease and dysphagia, had family members report that the food was cold and lacked options for softer foods, leading to her refusal to eat. Resident #22, who is cognitively intact and has Type 2 Diabetes Mellitus, reported that the food was not consistently served at a palatable temperature, with meat often being tough. These consistent reports from residents highlight a significant deficiency in the facility's ability to provide meals that meet the residents' expectations for temperature and taste, potentially impacting their nutritional intake.
Deficiency in Staff Training for Abuse Prevention
Penalty
Summary
The facility failed to maintain and monitor an effective training program for abuse prevention for all staff, which resulted in the potential for decreased resident safety. During an interview, the Director of Nursing (DON) reported that the facility lacked a staff development role and that she was responsible for monitoring the completion of assigned online trainings. The facility also did not have an on-site human resources employee, with training records being maintained at the corporate level. A former Nursing Home Administrator indicated that abuse education was completed online annually, with the last session occurring in the summer. A review of the Course Completion History for the Abuse, Neglect, and Exploitation module revealed that it was due on July 31, 2024, and out of 66 employees, 11 had not started the module, while the DON and a Unit Manager were still in progress. The facility was unable to provide documentation confirming the completion of abuse training by all employees by the time of the survey exit.
Deficiency in Meal Service and Call Light Response Times
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity during meal times for three residents. Observations revealed that during lunch service in the main dining room, residents were not served in a consistent order, leading to some residents waiting longer for their meals. For instance, Resident #14, who has Alzheimer's disease and moderate cognitive impairment, was observed waiting longer than others at her table to be served. Resident #17, who is cognitively intact, expressed frustration about the lack of a specific pattern in meal service, noting that it was bothersome to see others served while she had to wait. The Unit Manager confirmed that staff are supposed to serve one table at a time, but this was not being followed. Additionally, Resident #60 reported long wait times for call light responses, sometimes up to an hour, which was corroborated by Resident Council Minutes and staff interviews. The expectation set by the facility was for call lights to be answered within 3 minutes or as soon as possible. The Director of Nursing confirmed this standard, but residents had complained about the delays, indicating a failure to meet the expected response times.
Failure to Update Care Plan Following Dementia Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident following a new diagnosis of dementia. The resident, who was cognitively intact with a BIMS score of 15/15, was diagnosed with dementia on 10/8/24. However, a review of the resident's care plan revealed no documentation of this diagnosis. During an interview, the Unit Manager confirmed the omission and acknowledged that the care plan should have been updated to reflect the resident's new diagnosis.
Inconsistent Application of Brace for Resident with Limited ROM
Penalty
Summary
The facility failed to consistently apply a positioning device, specifically a brace, for a resident with limited range of motion (ROM), which could potentially lead to decreased ROM, contractures, and pain. The resident, who was admitted with diagnoses including stroke, paralysis, and muscle weakness, had a care plan that required passive range of motion (PROM) exercises to the right hand and wrist before applying a right resting hand splint. Observations revealed that the resident was often without the brace or it was improperly applied, despite orders to monitor for skin breakdown and apply the brace every shift. During observations, the resident was seen without the brace or with it improperly applied, and the Rehab Director had to intervene to adjust the brace and perform ROM exercises. The Rehab Director noted that the brace was to be applied by CNAs each day, and there was no record of the resident refusing the brace. The facility's policy on restorative nursing emphasized maintaining or improving residents' abilities, including the use of assistive devices and ROM exercises, but these were not consistently implemented for the resident in question.
Inadequate PPE Usage During COVID-19 Outbreak and EBP Non-Compliance
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was utilized as required during a COVID-19 outbreak, leading to potential infection control deficiencies. During observations, multiple staff members were seen without surgical masks, despite the requirement due to the outbreak. Specifically, a CNA was observed entering a COVID-positive resident's room without proper eye protection, and a Registered Dietician entered the same room without any PPE, despite clear signage indicating droplet precautions were necessary. The Director of Nursing reported that staff were informed of PPE requirements through a messaging system, but compliance was not observed. Resident #40, who was COVID-positive, was under droplet/contact precautions, requiring staff to wear gowns, N95 masks, eye protection, and gloves. However, staff were observed not adhering to these requirements. For instance, a CNA was seen wearing an N95 mask over a surgical mask but did not use eye protection. Additionally, a Licensed Practical Nurse was observed with an N95 mask that did not cover her nose, and a Registered Dietician entered the resident's room without donning any PPE, despite the resident still being under isolation precautions. Resident #17 was on Enhanced Barrier Precautions (EBP) due to a stage two sacral pressure ulcer, requiring gowns and gloves for direct care. However, during an observation, an LPN and a CNA provided care without donning gowns, indicating a lack of awareness of the EBP requirements. Interviews with staff revealed confusion and lack of awareness regarding the current precautions for Resident #17, despite the presence of a sign on the door and a care plan indicating the need for EBP. The Unit Manager confirmed that EBP was initiated for the resident due to the new wound, but staff failed to comply with the necessary precautions.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functioning call light system for a resident, which could potentially result in delayed response and negative outcomes. The resident, who had a history of fracture, unsteadiness, chronic pain, muscle weakness, osteoporosis, hearing difficulties, and other conditions, was observed with a call light system that was not within reach. The resident expressed concerns about staff not responding promptly to her call light, and it was noted that the call light system only emitted a single ding, which could be confused with the front doorbell, and did not illuminate the light above the door. Interviews with staff revealed that the call light system had been malfunctioning, with reports of a short in the system and issues with the electrical wiring within the wall. The facility had provided the resident with a doorbell pendant as an alternative alert system, but this was not effective as it only dinged once and could be easily missed. Observations confirmed that the call light was not consistently working, and staff had to repeatedly plug and unplug the system to get it to function. A work order had been submitted to address the issue, but it had not been resolved by the due date.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, involving three residents with varying degrees of cognitive impairment. Resident #101, who was severely cognitively impaired, was found in a situation where another resident, Resident #102, who was cognitively intact, had his hand up her shorts. This incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing. Resident #101 appeared confused and unaware of the situation, and the facility's response was to separate the residents and instruct Resident #102 to stay away from Resident #101. Additionally, the facility did not adequately manage the interactions between Resident #103 and Resident #104, both of whom had cognitive impairments and guardianship. Despite the guardians' consent for limited physical contact, the facility allowed these residents to engage in sexual interactions, including fondling and being found in compromising situations. Staff members were unclear about the boundaries set by the guardians and often allowed the residents to be alone in private rooms, believing they were permitted to have sexual interactions. This lack of clear communication and documentation regarding the guardians' consent led to multiple incidents of inappropriate contact between the residents. The facility's policies and procedures failed to prevent these incidents, as there was no clear documentation or communication regarding the boundaries of the residents' interactions. Staff members were not adequately informed or trained on how to handle the situation, leading to confusion and inappropriate actions. The facility's abuse policy, which was supposed to prevent non-consensual sexual contact, was not effectively implemented, resulting in the failure to protect the residents' rights to be free from abuse.
Inadequate Investigation and Prevention of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse and prevent further potential abuse. The incident involved a cognitively impaired resident who was allegedly abused by another resident who was cognitively intact. The incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing (DON). Initial interventions included separating the residents, placing them on 15-minute checks, and moving the victim to another room. However, the facility did not conduct a comprehensive investigation or implement sufficient measures to prevent further incidents. Interviews with staff revealed that the only intervention consistently reported was the 15-minute checks on the alleged perpetrator. Staff expressed concerns about the effectiveness of these checks, especially during times of short staffing. The facility did not assess the alleged perpetrator for underlying behaviors or triggers, nor did they update the care plan to address the potential for further incidents. The Social Services Manager and other staff confirmed that no additional interventions were considered to prevent the alleged perpetrator from targeting other residents. The facility's investigation was deemed inadequate as it did not substantiate the abuse, and no further assessments or interventions were conducted. The DON and former Nursing Home Administrator (NHA) acknowledged the lack of documentation and assessment of the alleged perpetrator's behaviors. The facility's failure to implement comprehensive interventions and conduct a thorough investigation resulted in additional allegations of abuse by the same resident, highlighting a significant deficiency in the facility's response to the initial incident.
Failure to Document Resident Interactions and Update Care Plans
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for staff and providers not having all pertinent information to care for them. Resident #103, diagnosed with Alzheimer's disease, and Resident #104, diagnosed with cognitive communication deficit and Wernicke's encephalopathy, both had care plans indicating a potential for behaviors that sound or appear sexual in nature. Despite these care plans, multiple incidents of sexual interactions between the two residents were observed by staff but not documented in their electronic health records (EHR). Certified Nursing Assistants (CNAs) and a Registered Nurse Unit Manager (RN-UM) reported witnessing sexual interactions between the two residents in the facility's courtyard. These incidents were reported verbally to supervisors but were not documented in the residents' EHRs. The RN-UM believed documentation was unnecessary due to the existing care plans that required redirection of such behaviors. Additionally, a Social Services Manager discussed consent boundaries with Resident #104's guardian but failed to document the conversation or update the care plans accordingly. The Nursing Home Administrator (NHA) became aware of an alert in the EHR regarding an incident involving the two residents, but upon investigation, found the documentation to be inaccurate. The lack of documentation and communication among staff members led to incomplete medical records, which could hinder the facility's ability to provide appropriate care and interventions for the residents involved.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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