Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 1881 E Grand Blvd, Detroit, Michigan 48211
- CMS Provider Number
- 235454
- Inspections on file
- 33
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident's room and bathroom were found to be in disrepair and unclean, with issues such as chipped paint, holes in the wall, thick dust on the fan and vent, black residue on bathroom walls, and unpleasant odors. The resident, who had multiple chronic conditions and intact cognition, reported the facility had long been aware of the need for repairs and cleaning. Staff interviews confirmed lapses in reporting and addressing these environmental concerns.
A resident with a history of cardiac issues was repeatedly reported by CNAs and a roommate to be in distress, exhibiting signs such as unresponsiveness and white foam at the mouth. Despite these reports, the RN on duty did not assess or monitor the resident, dismissing the concerns as the resident 'just sleeping.' The resident was later found unresponsive by the day shift nurse, who initiated emergency measures, but the resident was pronounced deceased. The failure to assess and respond to the change in condition constituted a deficiency in care.
The facility was found to have sanitation and supply deficiencies, including a lack of trash can liners, soiled shower gurney pads, and missing paper towels at handwashing sinks. Observations on multiple floors revealed these issues, with staff acknowledging the need for proper cleaning and supply maintenance. Despite this, no further documentation was provided during the exit conference.
A resident with severe cognitive impairment and multiple health conditions suffered a facial laceration in a facility. The LPN failed to perform necessary neurological checks or complete an incident report. Despite hypoglycemia being monitored, other vital signs were not reassessed, leading to the resident's transfer to a hospital for bradycardia and hypoglycemia. The DON noted procedural failures, including lack of proper monitoring and documentation.
The facility failed to ensure medications for three residents were not expired. An LPN observed that menthol-zinc oxide ointment for three residents and a tube of diclofenac sodium were expired. The LPN and DON acknowledged that these medications should have been reordered and discarded. No additional information was provided during the exit conference.
The facility's kitchen was found to be unsanitary, with dirty floors, overflowing trash, and inappropriate storage of items like charcoal and fire starter liquid. Equipment and food storage practices were inadequate, with expired spices, undated food items, and incomplete temperature logs. The facility's pest control reports indicated ongoing cleanliness concerns. The administrator acknowledged the issues, but the deficiencies have the potential to affect all residents consuming food from the kitchen.
The facility failed to maintain a safe and functional environment, with issues such as broken privacy curtains, a damaged bed, and defective televisions. Residents reported maintenance concerns, including a broken bed and a worn wheelchair, which were not promptly addressed. The facility's elevators and common areas also showed signs of neglect, with non-functional indicator lights and stained ceiling tiles.
Two incidents of resident-to-resident abuse occurred in the facility, resulting in significant injuries. In one case, a resident was pushed from their wheelchair by another resident, leading to a head injury. In another incident, a confrontation between two residents resulted in physical injuries. Both incidents were not adequately monitored by staff, highlighting deficiencies in ensuring a safe environment.
The facility failed to ensure PASARR forms were reviewed and submitted for two residents, leading to potential unmet care needs. One resident with severe cognitive impairment did not receive a necessary Level II screening, while another had an outdated PASARR form with no recent assessment. The facility's policy requires timely evaluations and tracking of PASARR status, which was not followed.
The facility failed to follow professional standards for medication administration for two residents. One resident's medications were left unattended and improperly crushed without a physician's order, while another resident missed multiple doses due to unavailability. The facility's policies require physician orders for crushing medications and immediate reordering of unavailable medications, which were not followed.
The facility failed to monitor the weight of two residents at nutrition risk, leading to undetected weight changes. One resident with a feeding tube had inconsistent weight records, and another experienced a significant weight loss that was not promptly addressed. The facility's weight monitoring policy was not followed, resulting in these deficiencies.
A resident with a feeding tube experienced frustration and complications due to the facility's failure to remove the tube despite no longer needing it. The resident was able to eat and drink normally, and the tube was causing infection and leakage. Staff were aware and advocated for removal, but the physician refused, leading to the deficiency.
A facility experienced a 37.1% medication administration error rate due to a nurse's inability to access the MAR on the medication cart, leading to reliance on memory and paper notes. This resulted in multiple errors for two residents, including incorrect dosages, administering medications not ordered, and failing to administer scheduled medications. The DON confirmed no electronic issues and emphasized the importance of following the facility's Medication Administration policy.
A resident with paraplegia and multiple sclerosis did not receive physician-ordered lab tests due to a failure in the facility's process. The tests, scheduled every three months, were not completed for June-July 2024 because the lab did not receive the order. The DON confirmed the oversight, which violated the facility's policy on timely lab services.
A resident with severely impaired cognition and missing teeth was not scheduled for a physician-ordered dental appointment due to a lack of consent from the legal guardian. The facility failed to document a request for consent, resulting in the resident not receiving necessary dental care.
A facility failed to ensure PPE was worn during wound care for a resident with a Stage III pressure ulcer. Despite signage indicating enhanced barrier precautions, a nurse performed wound care without PPE. The resident had impaired cognition and was dependent on most ADLs. Facility policy requires gowns and gloves during high-contact activities to prevent transmission of multidrug-resistant organisms, but staff did not adhere to these guidelines.
A resident with dementia reported $150 missing from their coat pocket, but the facility's investigation was insufficient. Only three CNAs were interviewed, and the police were not notified. The facility's policy requires a thorough investigation and law enforcement notification, which were not fully executed.
Failure to Maintain Clean and Homelike Resident Room and Bathroom
Penalty
Summary
A deficiency was identified when one resident's room was found to be in poor repair and unclean during observation, interview, and record review. The room had a loud unpleasant odor, chipped paint, holes in the wall over the bed, and a fan with thick dust particles blowing from it. The bathroom contained multiple areas of black residue on the wall and behind the toilet, a vent covered with thick dust, holes in the wall near the tissue holder, and brown stains and scuff marks on the bathroom door. The resident confirmed that the bathroom was filthy and uncomfortable, and stated that the facility had been aware of the needed repairs and cleaning for a long time. During interviews, the Maintenance Director acknowledged the worsening condition of the black areas on the wall, attributing them to mud used for sealing cracks and holes, and stated that staff are supposed to report such issues in the TELS system for repair orders. The Maintenance Director also indicated that housekeepers are responsible for dusting vents and fans, and agreed that the level of dust was unacceptable. The Regional Director of Operation confirmed the need for cleaning and repairs in the room and bathroom. The resident involved had diagnoses including chronic obstructive pulmonary disease, hypertension, multiple sclerosis, and Parkinsonism, and was assessed as having intact cognition.
Failure to Assess and Respond to Change in Condition Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to assess and monitor a resident who exhibited a change in condition, resulting in a lack of timely emergency medical intervention. The resident, who had a history of significant cardiac issues including myocardial infarction, hypertension, and episodes of unresponsiveness, was reported by both their roommate and two CNAs to be in distress around 5 a.m. The CNAs and the roommate observed the resident with their head tilted back, mouth open, and white foam coming from the mouth, and repeatedly notified the on-duty RN. Despite these reports, the RN did not perform an assessment, obtain vital signs, or attempt to arouse the resident, instead stating the resident was just sleeping and snoring, which was not unusual for them. The CNAs continued to express concern to the RN, but the RN did not return to the room or further evaluate the resident. The roommate also attempted to alert the RN multiple times and expressed regret for not calling 911 themselves. The RN later confirmed to the Director of Nursing that they were informed by staff and the roommate about the resident's condition but did not act, citing other tasks. The resident was ultimately found unresponsive by the day shift nurse, who immediately began emergency measures and called EMS, but the resident was pronounced deceased shortly thereafter. The resident's medical record indicated prior episodes of acute distress, including previous hospitalizations for heart attack and unresponsiveness, and a care plan that required monitoring for chest pain, shortness of breath, and changes in condition. The facility's policy required staff to recognize and manage changes in condition, but the RN failed to follow these protocols, resulting in a lack of timely assessment and intervention for the resident.
Plan Of Correction
Element 1: Resident 602 no longer resides at the facility. Element 2: Current residents are at risk for requiring emergency care or experiencing adverse events if Change of Condition is not recognized and assessed in a timely manner. Education was completed prior to survey including review for other residents to determine any ongoing needs secondary to Change in Condition. A follow-up 1x audit was completed for the past 3 days to determine any residents experiencing a Change of Condition that required further assessment or monitoring. Concerns were addressed as needed. Element 3: Current staff were re-educated on Recognizing Change of Condition and steps to take regarding needed assessments and monitoring. Licensed nurses were re-educated on needed assessments, documentation, and notification when a Change of Condition is recognized. Staff who do not receive the education by the date of compliance will receive education on the day of work. Non-compliance with the education on the day of work. Non-compliance with the education will result in 1:1 education or written discipline per policy. System Change: Increase Monitoring. Element 4: DON/designee will complete audits of 24-hour report for Change of Condition including any needed Assessment and Documentation daily M-F x 4 weeks then weekly x 4 weeks and ongoing per QA committee recommendations. Results of audits will be reported to QAPI monthly x 3 months and PRN. DON is responsible for ongoing compliance.
Sanitation and Supply Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary and adequately supplied environment, as observed during a tour of the third and second floors. On the third floor, a trash can in a resident's room lacked a liner and contained trash, while the shower gurney pad was found to be soiled and stained. Additionally, the handwashing sink in the shower room lacked paper towels and a waste receptacle. Similar issues were noted on the second floor, where no paper towels were available for the handwashing sink in the shower room. Further observations on the third floor revealed that the trash can still lacked a liner, and the shower gurney pad remained soiled. Housekeeper J noted specific stains on the gurney pad, indicating it had not been cleaned properly. CNA K confirmed the gurney pad should be washed and dried after use, and the DON stated that the gurney should be disinfected after each use, and trash cans should be cleaned, disinfected, and lined. Despite these acknowledgments, no additional documentation or information was provided by the Nursing Home Administrator or DON during the exit conference.
Inadequate Assessment and Monitoring After Resident Injury
Penalty
Summary
The facility failed to provide adequate assessment and care for a resident, identified as R105, following an injury. R105, who had severe cognitive impairment and multiple diagnoses including vascular dementia and diabetes mellitus-type 2, was found with a laceration on the right side of the face. The incident occurred when the resident was resting her head on a table. Despite the injury, there was no documented assessment of vital signs such as blood pressure, respirations, pulse oximetry, or heart rate between the time of the injury and the resident's transfer to the hospital. The Licensed Practical Nurse (LPN) responsible for R105 at the time of the incident did not perform necessary neurological checks or complete an incident report. The LPN attempted to contact the primary care provider but only reached a voicemail. The resident's blood sugar levels were monitored, revealing hypoglycemia, but other vital signs were not reassessed. The Director of Nursing (DON) noted that the LPN should have initiated neurochecks and monitored the resident more closely following the injury. The resident was eventually transferred to a local hospital due to bradycardia and hypoglycemia. The DON acknowledged that the LPN did not follow proper procedures, including failing to notify the DON and not completing an incident report. The facility's documentation was incomplete, lacking evidence of consistent monitoring and vital sign assessments during the critical period following the injury.
Expired Medications Found in Treatment Cart
Penalty
Summary
The facility failed to ensure that medications for three residents, identified as R113, R115, and R116, were not expired. During an observation of the second-floor treatment cart with an LPN, it was found that a four-ounce tube of menthol-zinc oxide ointment for R113 had expired on 9/5/24, for R115 on 10/27/24, and for R116 on 10/4/24. Additionally, a 3.53-ounce tube of diclofenac sodium was found to have expired on 3/28/24. The LPN acknowledged that these medications should have been reordered and the expired ones discarded. The DON confirmed that the outdated medications should have been discarded and the diclofenac sodium reordered. No additional documentation or information was provided by the Nursing Home Administrator and DON during the exit conference.
Sanitation and Equipment Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during an initial tour with the Dietary Manager (DM). The kitchen floor was dirty with brown stains and food debris, and trash cans were overflowing with food waste. The dry storage room contained inappropriate items such as an open bag of charcoal and fire starter liquid stored with kitchen items. Additionally, the food prep area was cluttered with dust, debris, and non-functional equipment, including a slicer and a strainer. The walk-in cooler and freezer were not properly maintained, with issues such as ice buildup and improperly stored food items. The facility's equipment and food storage practices were inadequate, as evidenced by expired spices and undated food items in the spice rack and storage areas. The dish machine temperature logs were incomplete, and there were leaks in the three-compartment sink drains. The basement storage freezer had significant ice buildup, and the temperature fluctuated when the door was opened. The facility's pest control reports indicated ongoing cleanliness and sanitation concerns, which had been previously brought to the facility's attention. During a follow-up observation, the kitchen staff lacked a working thermometer to check food temperatures, and the cooking temperature logs were incomplete. The facility administrator acknowledged the concerns and mentioned that the new dietary manager was implementing systems to ensure staff followed facility processes. However, the report highlights the facility's failure to maintain a clean and safe kitchen environment, which has the potential to affect all residents consuming food from the kitchen.
Deficiencies in Facility Maintenance and Resident Equipment
Penalty
Summary
The facility failed to maintain a safe and functional environment, as observed in multiple resident rooms and common areas. In one room, privacy curtains were not functional, with broken hooks and unclean conditions, including a large reddish-brown stain. Another room had a broken bed with a missing footboard, and the resident reported that it had been broken for about a month. Despite the resident's report, no maintenance had been conducted to fix the bed. Additionally, a bedside table in another room was missing veneer, creating non-cleanable and sharp areas. Further deficiencies were noted in the facility's provision of entertainment equipment. A resident reported not having a television in their room despite requests, and another resident's television was defective, with a distorted picture. The facility's elevators also had issues, with non-functional floor indicator lights and slow operation, causing inconvenience to users. Ceiling tiles with brown stains were observed in the hallway, indicating potential water damage or leaks. A resident's wheelchair was found to be in poor condition, with multiple ripped spots and missing foam on the armrest. Despite the resident's need for a new wheelchair, it remained unchanged over several days. The facility's maintenance director reported that issues were addressed when brought to their attention, but the observations suggest a lack of timely response to maintenance needs. The facility was under new management, which was reportedly in the process of making improvements to the physical environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure an environment free from physical abuse for two residents, resulting in significant injuries. One resident was pushed over in their wheelchair by another resident, leading to a head injury and hospitalization. The incident occurred in the dining room, where the resident was attempting to protect another female resident from the aggressor's advances. The aggressor, who had a history of restlessness and agitation, was not being adequately monitored by staff at the time of the incident. Another incident involved a physical altercation between two residents, where one resident entered another's room uninvited, leading to a confrontation. The resident who was intruded upon reported being hit and responded by hitting the intruder multiple times, resulting in visible injuries. Both residents involved in this altercation had cognitive impairments, with one having a severely impaired cognition score. The staff did not witness the incident, and the altercation was only reported after the fact. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of staff intervention and monitoring in both incidents. The facility's investigation confirmed the occurrences of these altercations, highlighting deficiencies in maintaining a safe environment for residents. The incidents were substantiated based on injuries, staff reports, and resident accounts, indicating a failure to protect residents from abuse and ensure their safety.
Failure to Complete PASARR Level II Screenings
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Annual Resident Review (PASARR) forms were properly reviewed, revised, and submitted to the local state agency for two residents, resulting in potential unmet intellectual and developmental disability care needs. Resident R102 was admitted with diagnoses including major depressive disorder and psychotic disorder. The Minimum Data Set (MDS) indicated severe cognitive impairment and a need for assistance with daily activities. Although a PASARR form was completed, a necessary Level II screening was not requested, and the social worker acknowledged the oversight during an interview. Resident R79, with diagnoses including schizoaffective disorder and delusional disorders, had a PASARR form dated over two years prior, with no updated assessment in the record. The social worker indicated that the previous social worker should have updated the form and sent it to the local Community Mental Health Services Program for a Level II assessment. The current social worker had not yet reviewed R79's case but was working to update outstanding assessments. The facility's policy requires coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities. The policy outlines the need for timely Level II evaluations and the responsibility of the Social Services Director to track PASARR screening status. However, the facility did not adhere to these guidelines, leading to the deficiencies noted in the report.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for two residents, R101 and R44. For R101, medications were left unattended on the breakfast tray, and extended/delayed release medications were crushed without a physician's order. R101, who had severely impaired cognition and required assistance with eating, was observed with a medication cup containing nine whole pills on his breakfast tray. Registered Nurse G admitted to crushing the medications without an order, stating it was easier for R101 to take them that way. The facility's policy requires a physician's order for crushing medications, and the medications in question should not have been crushed according to the manufacturer's guidelines. For R44, the facility failed to ensure the availability of prescribed medications, resulting in missed doses. R44, who had moderately impaired cognition, was not administered their prescribed Fluticasone spray and Claritin on multiple occasions. Nurse S confirmed the unavailability of Fluticasone in the medication cart and indicated it needed to be reordered. The Director of Nursing acknowledged that the standard practice was to reorder medication after the first missed dose and that the nursing staff needed education on proper procedures. The facility's guidelines emphasize the importance of administering medications as prescribed and documenting the administration immediately. The deficiencies highlight a lack of adherence to medication administration protocols, including the improper crushing of medications and failure to ensure the availability of prescribed medications. These actions and inactions led to the residents not receiving their medications as intended, which is a violation of professional standards and facility policies.
Failure in Weight Monitoring for Residents at Nutrition Risk
Penalty
Summary
The facility failed to ensure proper weight monitoring for two residents at nutrition risk, leading to undetected weight changes. Resident 27, who had a history of stroke, dysphagia, and dementia, was observed with a tube feeding setup but no feeding present. The resident's weight had not been documented since May, despite a significant weight loss noted in March. A Registered Dietitian indicated that residents receiving tube feedings should be weighed at least monthly if stable, or weekly if there are significant changes. However, the resident's weight was not recorded until August, and a discrepancy of 14.4 pounds was noted within three days, which could not be explained by the Director of Nursing. Resident 71, with diagnoses including schizophrenia and alcohol abuse, experienced a 20-pound weight loss over three weeks, which was not addressed promptly. The resident's weight records showed consistent weights until a sudden drop in July. The Registered Dietitian requested a re-weigh, and the weight was confirmed to be accurate, but the significant weight change was not explained. The facility's weight monitoring policy requires weights to be obtained upon admission, weekly for the first four weeks, and at least monthly thereafter, with significant changes defined by specific percentages over set periods. The failure to adhere to this policy resulted in undetected weight changes for both residents.
Failure to Remove Unnecessary Feeding Tube
Penalty
Summary
The facility failed to remove a feeding tube from a resident, R29, when there was no longer a valid clinical indication for its use. R29 expressed frustration with the presence of the unused feeding tube, which was causing swelling, redness, and drainage at the insertion site, as well as leakage through visible holes in the tube. Despite the resident's ability to eat and drink normally, and having gained weight, the physician refused to remove the tube, leading to the resident's discomfort and dissatisfaction. Observations revealed that the feeding tube was not properly secured and was leaking, causing stains on the resident's clothing. The resident was observed eating regular meals without difficulty and consuming a significant portion of his meals. The nursing staff, including RN C, were aware of the issues with the feeding tube and had been advocating for its removal, but the physician did not respond to their requests. The Director of Nursing (DON) also communicated with the physician, who insisted on keeping the tube in place due to concerns about potential weight loss. The facility's policy on feeding tubes requires that they be used according to physician orders and that any complications be reported to the physician. Despite signs of infection and the resident's improved nutritional status, the feeding tube was not removed. The resident's legal guardian was also informed of the situation and expressed confusion as to why the tube had not been removed, given the resident's ability to eat and gain weight. The facility's failure to address the resident's concerns and the complications associated with the feeding tube led to the deficiency noted in the report.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a 37.1% error rate. This was observed during a medication administration process involving two residents. Registered Nurse (RN) C was unable to use the computer on the medication cart to access the Medication Administration Record (MAR) and instead used a computer at the nurse's station to write down medications on paper. This led to multiple medication errors for Resident R73, including administering medications that were not due, incorrect dosages, and medications that were not ordered. Additionally, RN C failed to administer several prescribed medications that were scheduled for the 10:00 AM dose. For Resident R29, RN C also made errors by administering a medication that was not ordered and failing to administer two medications that were scheduled for the 10:00 AM dose. RN C admitted to relying on memory for some medications and mentioned a verbal order from a physician that had not been processed. The Director of Nursing (DON) confirmed that there were no electronic issues and that printed MARs were available as a backup. The DON stated that RN C should have contacted the unit manager instead of relying on memory or paper notes. The facility's Medication Administration policy emphasizes the importance of administering medications as prescribed and following the Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time). The policy also outlines procedures for verifying medications against the MAR at multiple stages. However, RN C's actions deviated from these procedures, leading to the observed medication errors.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident diagnosed with paraplegia and multiple sclerosis. The resident, who had intact cognition, was admitted to the facility with a physician's order for several laboratory tests to be conducted every three months starting in April 2024. However, upon review of the resident's medical record, it was found that the laboratory results for June-July 2024 were missing, indicating that the ordered tests were not completed as required. During an interview with the Director of Nursing (DON), it was revealed that the facility did not have the lab results for the specified period due to an issue with the laboratory not receiving the order. The facility's policy mandates the provision of timely laboratory services, but in this case, the facility did not meet this requirement, resulting in a deficiency. The DON acknowledged the oversight and indicated that the lab orders would be rewritten and followed up for completion.
Failure to Schedule Dental Appointment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to schedule a physician-ordered dental appointment for a resident with severely impaired cognition, resulting in the resident not being seen by a dentist. The resident, who was admitted with Medicaid benefits and had diagnoses including schizophrenia and alcohol abuse, was observed with missing and decayed teeth. A physician had ordered a dental evaluation for the resident due to left jaw swelling, but there was no documentation indicating that the resident had been seen by a dentist. The social worker acknowledged that the dentist had not seen the resident because the legal guardian had not signed a dental services consent form. However, there was no documentation in the electronic health record to show that the legal guardian had been requested to sign the consent form. The legal guardian confirmed that they had not been asked to provide consent but would have done so immediately if requested. The facility's policy requires assisting residents in obtaining dental care, but this was not followed in this case.
Failure to Use PPE During Wound Care
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was worn during wound care for a resident with a Stage III pressure ulcer. During an observation, a registered nurse (RN) entered the resident's room to perform wound care without applying any PPE, despite signage on the door indicating the need for enhanced barrier precautions. The resident, who had impaired cognition and was dependent on most activities of daily living, was admitted with a diagnosis of a pressure ulcer on the right buttock. The facility's policy on enhanced barrier precautions, last revised in March 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. Interviews with the Director of Nursing and the Infection Control Preventionist confirmed that staff should follow these guidelines and wear PPE during wound care. However, the RN and assisting staff did not adhere to these precautions, leading to the deficiency.
Inadequate Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation involving a resident's missing money. The resident, who had dementia and moderately impaired cognition, reported that $150 was missing from their coat pocket. The facility's investigation was limited to interviewing three CNAs, none of whom reported seeing the money or being near the coat after it was hung up. The resident could not recall the exact amount of money initially reported, and the facility did not verify the source of the funds, as they typically do not distribute $50 bills. The facility's administrator, who is also the abuse coordinator, did not interview other staff or residents who might have had contact with the resident or could have witnessed the incident. Additionally, the police were not notified of the allegation because the facility did not witness the resident having the money. The facility's policy requires a comprehensive investigation, including interviewing all involved parties and notifying law enforcement when necessary, but these steps were not fully executed in this case.
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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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