Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Grandville, Michigan.
- Location
- 3400 Wilson Avenue, Grandville, Michigan 49418
- CMS Provider Number
- 235039
- Inspections on file
- 23
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food service operations, including improper cleaning and maintenance of kitchen equipment, failure to prevent backflow in a steamer drain, lack of proper cooling documentation for food items, and soiled storage areas. These issues affected 75 residents and increased the risk of cross-contamination and bacterial harborage.
The facility did not follow infection prevention and control policies, including proper management of C. diff infection, hand hygiene, and cleaning of shared medical equipment. Two residents were affected by inadequate contact precautions, and staff failed to clean a glucometer, blood pressure cuff, and mechanical lifts between uses. Staff were also not properly educated on handling contaminated linens, and necessary supplies were missing from designated areas.
Nursing staff failed to document controlled medication administration at the time of dispensing, administered medications with specific parameters without obtaining current vital signs, and did not consistently follow or document orders related to anticoagulant therapy. These actions included giving antihypertensive medications without current BP or pulse checks and administering warfarin despite orders to hold, with incomplete PT/INR documentation. Staff interviews revealed confusion about protocols and inconsistent practices.
A resident with multiple mobility-related diagnoses was provided with a manual wheelchair that did not fit her properly after her electric wheelchair was removed for safety reasons. The resident was unable to reach the floor with her feet, resulting in loss of independence, discomfort, and difficulty with self-propulsion. Facility staff acknowledged the poor fit but did not document efforts to find a more suitable wheelchair or provide evidence of proper fitting.
A resident experienced multiple episodes of severely elevated blood pressure that were not promptly reassessed or reported to the provider, as required by facility policy. The provider only became aware of these abnormal readings by reviewing the electronic health record, and there was no documentation of direct provider notification or timely follow-up by nursing staff.
A resident with chronic kidney disease, diabetes, and obesity experienced significant weight gain and edema, but staff failed to assess these changes or complete a physician-ordered ammonia lab. Nursing and management were unaware of the resident's condition changes until prompted, and required interventions such as reweighing, provider notification, and resident education were not carried out.
A resident with severe cognitive impairment and high risk for pressure ulcers was not provided with appropriate preventative care, as staff failed to regularly reposition her despite clear indications and facility policy. The care plan did not reflect her high risk status, and staff interviews revealed a lack of awareness regarding repositioning protocols, resulting in the development of a large, painful, reddened area on her coccyx.
A resident with severe cognitive impairment and limited range of motion was repeatedly observed in bed with her left foot in a plantar flexion position, indicating foot drop, without any care plan interventions or staff awareness to address her positioning or ROM needs. Staff interviews revealed no orders for repositioning, and the condition was only recognized after hospice assessment, despite ongoing observations of the issue and the resident's discomfort.
A resident with Alzheimer's and severe cognitive impairment was found tightly wrapped in a blanket, restricting movement, after a CNA left the facility early without notifying the nurse on duty. The resident was wet, with the incontinence brief on backward, indicating neglect. The CNA claimed the resident tangled herself, but this was inconsistent with the resident's condition.
The facility failed to ensure a safe environment and adequate supervision for residents, leading to multiple deficiencies. A resident with cognitive impairment had her call light out of reach, increasing fall risk. Another resident was left unattended with an unlocked wheelchair, and a third struggled with a hoyer lift in a cluttered hallway. Additionally, two residents with dietary restrictions were unsupervised while eating, posing a choking risk. These incidents highlight lapses in following care plans and facility policies.
The facility failed to maintain cleanliness and repair, with issues such as lack of backflow prevention in the Beauty shop, dust and debris in linen closets, and improper storage of slings in the 300 shower room. Additionally, a large hole was found under the sink in the lakeshore dining room, which the new Maintenance Director was unaware of.
The facility failed to maintain a safe and clean environment for two residents. One resident, who is non-ambulatory, had a cluttered room with personal belongings spread across surfaces, and staff had not offered assistance despite the resident's desire to organize. Another resident, with severe cognitive impairment, had communication boards repeatedly found coated in a sticky substance, indicating a lack of attention to cleanliness. The care plans and documentation did not address these issues.
A resident missed a scheduled colonoscopy due to the facility's failure to monitor and assist with a bowel preparation protocol. The resident, who was cognitively intact, was left to self-administer medication without proper assessment or monitoring. On the day of the procedure, the resident woke up soiled and panicked, unable to get assistance from busy CNAs. The incident was not documented or reviewed, and the resident was left to clean himself up without staff support.
A facility failed to maintain range of motion and prevent skin breakdown for a resident with a severe contracture. The resident, with a history of hemiplegia and other conditions, was observed with her left hand in a fist position, lacking proper care interventions. Staff noted skin irritation, but the care plan did not include necessary interventions for the resident's hand.
A facility failed to assess and develop a care plan for a resident with PTSD, severe intellectual disabilities, and a history of childhood abuse. The care plan lacked focus on PTSD, and staff were unaware of the resident's history, leading to distress when a male visitor entered the room. The DON acknowledged the oversight in care planning for the resident's PTSD.
A facility failed to provide collaborative hospice care for a resident with multiple health issues, resulting in potential unmet needs. Staff were unaware of hospice services provided, and there was a lack of documentation and communication regarding the resident's hospice care plan. The hospice provider's access to the facility's electronic medical charting system was not functioning, contributing to the deficiency.
A resident with a Foley catheter and biliary drain had her collection bags in contact with the floor, violating infection prevention protocols. A CNA was unsure how to keep the bags off the floor while maintaining the bed in a low position, leading to improper handling. The resident's care plans lacked specific instructions for proper bag placement, contributing to the deficiency.
A diabetic resident's blood sugar levels were not monitored while receiving long-acting insulin due to a communication breakdown between medical providers and nursing staff. The oversight occurred after the discontinuation of short-acting insulin, which inadvertently stopped the associated blood sugar monitoring order. Staff interviews revealed the importance of checking blood glucose levels before insulin administration.
A resident admitted for short-term rehab experienced severe neglect, leading to physical deterioration and death. The facility failed to follow hospital discharge instructions, provide adequate wound care, ensure hydration and nutrition, and prevent a fall. The resident developed multiple severe pressure injuries, contracted COVID-19, and was admitted to the hospital with septic shock and malnutrition. The resident was placed on hospice care and died of sepsis.
The facility failed to provide quality care to three residents, resulting in untreated sepsis and septic shock for one resident. A resident with Huntington's disease experienced multiple instances of inadequate care, including missed medication doses and delayed assessments. Another resident with cerebral palsy had no follow-up documentation after being prescribed an antibiotic for a penile infection. A third resident with urinary retention had no documentation of required catheterizations despite high bladder scan results.
The facility failed to provide adequate supervision for two residents, resulting in fractures, and did not implement documented care interventions for another resident, leading to potential safety hazards.
The facility failed to ensure timely response to call lights, accessibility of call lights, and availability of fluids for six residents, leading to delays in meeting their needs. Staff shortages and non-compliance with facility policy contributed to the deficiencies.
The facility failed to follow professional standards for medication administration for four residents, resulting in medications not being administered according to physician orders and outside of ordered parameters. Staff interviews revealed non-compliance with medication administration policies and lack of vital sign assessments prior to medication administration.
A resident with severe cognitive impairment and multiple physical disabilities was repeatedly observed in improper positions without protective boots and with foley collection tubing improperly placed. The Director of Therapy Services confirmed the resident should not be positioned in such a manner, indicating a failure to provide appropriate care to maintain or improve the resident's range of motion and mobility.
The facility failed to maintain accurate controlled substance counts and documentation for four residents. Interviews with LPNs revealed non-compliance with standards of practice, including sharing narcotic keys and delayed documentation. The Regional Director of Operations confirmed these errors, highlighting a failure to adhere to the facility's controlled substances policy.
The facility failed to follow established procedures for medication storage, with loose pills found in medication carts, an unsecured medication store room, and an unlocked refrigerator containing a controlled substance.
The facility failed to implement proper infection control practices, including inadequate hand hygiene and improper handling of soiled linens, leading to potential cross-contamination and infection risks for residents with pressure ulcers and other wounds.
A resident's colon cancer screening test remained incomplete due to facility errors and lack of follow-up. Despite multiple orders and the resident's guardian reporting the issue, the facility did not take prompt action to resolve the grievance, and the responsible medical personnel were not notified.
The facility failed to follow care plans and policies to prevent and treat pressure injuries for two residents, resulting in increased pain and worsening of wounds. One resident was observed with her heels not elevated as required, and another resident's wound treatment was delayed, leading to deterioration. Staff interviews revealed insufficient staffing to meet resident needs.
A facility failed to maintain and store nebulizer and supplemental oxygen supplies appropriately for a resident with chronic respiratory failure and COPD. Observations revealed improper handling and storage of respiratory equipment, including a CNA placing a nasal cannula on a pillow and handling it with soiled gloves. The facility's policy for cleaning and storing nebulizer equipment was not followed.
A resident with multiple diagnoses was prescribed antibiotics without proper documentation or assessment, leading to potential antibiotic resistance. The facility failed to adhere to its Antibiotic Stewardship Program, as there was no infection monitoring or user-defined assessments completed before starting the antibiotics. The clinical record lacked a risk versus benefit statement to justify the prescribed antibiotics, and the culture results did not represent a treatable infection.
The facility failed to provide adequate care and implement necessary interventions for pressure ulcers for two residents. One resident reported missed dressing changes and improper repositioning, while another resident experienced inadequate wound care and missed dressing changes. Staff interviews and records revealed communication gaps, lack of proper documentation, and insufficient follow-up on resident concerns and refusals.
The facility failed to follow care interventions for a resident with severe cognitive impairment and dysphasia. A CNA left a drinking cup within reach despite an NPO order and repositioned the resident without required assistance, leaving the resident unattended in a high bed position without the call light in reach.
The facility failed to implement proper infection control practices, including handling soiled linens, performing hand hygiene, and providing peri-care, leading to cross-contamination risks for multiple residents with pressure ulcers and other conditions.
The facility failed to provide scheduled showers and maintain hygiene for two residents, resulting in one resident having oily, matted hair and another lying on dirty sheets for weeks. Staff failed to adhere to care plans and properly document care, impacting the residents' dignity and well-being.
The facility failed to adhere to policies and best practices for a resident with a feeding tube, leading to potential issues with nutrition, hydration, and equipment contamination. Observations revealed incorrect water flush rates, lack of labeling, and improper handling of disposable items. Additionally, a CNA improperly placed the tube feed on hold without notifying a nurse.
The facility failed to follow procedures for administering and documenting controlled substances for a resident with chronic pain, resulting in discrepancies between the controlled substance record and the electronic medication administration record over multiple dates.
The facility failed to maintain locked treatment carts, resulting in the potential for accidental ingestion and misappropriation of physician-ordered treatments. Multiple observations revealed unlocked and unattended treatment carts containing prescription and OTC medications, as well as other items like bug spray. A nurse confirmed that treatment carts should be locked when unattended.
The facility failed to respond to call lights in a timely manner for three residents, leading to unmet needs and discomfort. One resident with a stage 4 pressure ulcer reported staff turning off his call light without addressing his needs. Another resident waited over 9 minutes for assistance, only to have his request ignored. A third resident, who is legally blind, waited over 26 minutes for her call light to be answered. Observations revealed staff were not attending to residents' needs promptly.
The facility failed to address and resolve grievances for a resident with significant medical needs, including missed dressing changes and long call light response times. Despite the resident reporting these issues to the administration, there was no documented follow-up or resolution.
A resident with severe cognitive impairment was found tightly wrapped in bed sheets, unable to move or use her call light for approximately 10 hours. The CNA responsible claimed it was to prevent the resident from ripping off her brief, but the facility found no evidence supporting this practice and terminated the CNA for abuse and neglect.
A resident with severe cognitive impairment and hemiplegia was not provided timely incontinence care, resulting in a saturated brief and a large macerated area on her buttocks. The care plan required regular checks and changes, but the facility failed to meet this standard, leading to the development of a Stage 1 pressure ulcer.
The facility failed to maintain and store nebulizer and supplemental oxygen supplies appropriately for a resident with chronic respiratory conditions, leading to potential cross-contamination. Observations revealed improper handling and storage of the equipment, and staff did not follow the facility's policy for cleaning and storing respiratory equipment.
The facility failed to implement its Antibiotic Stewardship Program for a resident, resulting in the potential for antibiotic resistance. The resident was prescribed antibiotics without proper assessment or documentation of infection monitoring. The medical records did not reflect any signs or symptoms of infection, and the attending physician or provider had not assessed the resident before initiating the antibiotic treatment. The Nurse Practitioner did not document a risk versus benefit statement to justify the prescribed antibiotics, and the Director of Nursing confirmed the lack of documentation related to infection tracking.
Deficient Food Service Equipment Maintenance and Food Cooling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, including improper maintenance and cleaning of equipment, and inadequate food cooling practices. The Accutemp Steamer was found with a drain line directly submerged into a sewer drainpipe, violating backflow prevention standards. There was a significant build-up of grease, grime, and food debris behind and under cooking equipment, and the can opener blade and some pans on the clean storage shelving were soiled with stuck-on food residue. The Kelvinator 3-door line cooler was out of service and not available for cold food storage, and a 3-door cooler had a burnt-out light bulb, reducing required light intensity. The ice machine filter lacked a date mark, and the Certified Dietary Manager (CDM) was unsure when it was last replaced. The walk-in freezer and cooler floors had food residue and debris, and condensation droplets were observed on food container lids, indicating possible cooling issues. Further review revealed that containers of Sloppy Joes and Ravioli in the walk-in cooler were not properly documented for cooling, as required by policy, and the daily temperature log did not include cooling records for these items. The nutritional refrigerator in the dining room was found with soiled and sticky shelving. These observations affected 75 residents and increased the likelihood of cross-contamination and bacterial harborage due to improper cleaning, maintenance, and food handling practices. The deficiencies were identified through direct observation, interviews with the CDM, and review of facility records and logs.
Failure to Implement Infection Control Policies and Equipment Cleaning
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures in several key areas, including the management of Clostridioides difficile (C. diff) infection, cleaning of reusable resident-care equipment, and proper hand hygiene. For one resident with an active C. diff infection, the care plan inaccurately listed an antiviral medication as an intervention, despite C. diff being a bacterial infection. The care plan and Kardex specified contact precautions but did not include further interventions for the resident or their roommate, who was ambulatory and at risk of spreading contamination due to frequent movement around the facility. Staff did not ensure that the roommate washed hands with soap and water before leaving the room, nor was the resident's walker cleaned after use, despite the risk of contamination. Observations revealed that staff did not consistently follow hand hygiene protocols specific to C. diff, such as washing hands with soap and water instead of using alcohol-based hand rubs, which are ineffective against C. diff spores. A certified nurse aide was observed leaving the room of a resident with C. diff without washing hands appropriately and was unaware of the correct protocol. Additionally, laundry staff had not been educated on handling linens contaminated with C. diff, and soiled linens were sometimes transported in regular bags instead of red biohazard bags, contrary to facility policy. There was also a lack of proper supplies, such as red or dissolvable bags, in the designated areas for staff use. The facility also failed to ensure proper cleaning and disinfection of shared medical equipment. A licensed practical nurse was observed using a glucometer and blood pressure cuff on multiple residents without cleaning the devices between uses, despite being aware of the policy requiring disinfection with appropriate wipes. The nurse did not know the location of the sanitizing wipes and admitted to using personal equipment without cleaning it after each use. Additionally, mechanical lifts used for resident transfers were visibly soiled and not cleaned regularly, with staff acknowledging the lack of cleaning supplies and infrequent cleaning of the equipment.
Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for multiple residents, as evidenced by incomplete and inaccurate documentation and failure to adhere to medication parameters. On the Garden Unit, review of the Narcotic Book revealed that nine residents did not have their scheduled morning controlled medications documented as dispensed since the previous day, and subsequent review showed that documentation was entered retroactively, not at the time of administration. This indicates that licensed nurses did not document the date and time of controlled medication administration as required by facility policy. For several residents receiving medications with specific parameters, such as antihypertensives, nurses administered medications without obtaining and assessing vital signs immediately prior to administration, instead relying on vital signs from previous shifts. For example, one resident received clonidine despite blood pressure readings below the ordered threshold, and two other residents received lisinopril without current blood pressure or heart rate assessments, with documentation showing use of previous shift vitals. These actions were contrary to provider orders and facility policy, which require assessment of vital signs within the medication pass window to ensure safe administration. Additionally, there were deficiencies in the monitoring and documentation of anticoagulant therapy for a resident with a history of heart disease and DVT. Orders to hold warfarin based on elevated PT/INR results were not followed, resulting in the medication being administered when it should have been held. Documentation of PT/INR results and related orders was incomplete, with missing entries and lack of clarity regarding therapeutic goals. Interviews with nursing staff revealed a lack of understanding of PT/INR protocols and inconsistent documentation practices, further contributing to the deficiency.
Failure to Provide Appropriately Fitting Wheelchair for Resident
Penalty
Summary
A deficiency was identified when the facility failed to assist a resident with finding an appropriately fitting wheelchair. The resident, who has diagnoses including lack of coordination, spinal stenosis with neurogenic claudication, morbid obesity, and osteoporosis, was previously using an electric wheelchair that was removed due to safety concerns and mechanical issues. She was transitioned to a manual wheelchair, which she found difficult to self-propel due to her feet not reaching the floor, resulting in loss of independence and physical discomfort, including bruising and skin breakdown from contact with the wheelchair. Observations and interviews revealed that the resident had to scoot forward in the seat to touch the floor with her toes, which staff discouraged for safety reasons. She reported using the wall rails to pull herself along and sometimes propelled herself backward, which caused shoulder soreness. The manual wheelchair provided was a 17-inch height model, and both the Rehabilitation Director and Physical Therapy Assistant acknowledged that it did not fit her properly, with her feet being several inches from the floor. Despite these issues, facility staff stated that no lower wheelchair was available and did not provide documentation of efforts to find a more suitable option. Physical therapy notes documented ongoing problems with wheelchair mobility, discomfort, and attempts to modify the wheelchair with a lower profile cushion, which only partially addressed the issue. The care plans indicated that the manual wheelchair was considered to meet her needs, but the resident continued to experience pain and difficulty with mobility. No evidence was provided to show that alternative wheelchair options were explored or that the resident was properly fitted for her current wheelchair.
Failure to Notify Provider of Abnormal Blood Pressure Readings
Penalty
Summary
The facility failed to notify the provider of abnormal vital signs for one resident, as required by policy. The resident, an elderly female, had multiple episodes of significantly elevated blood pressure readings, including 209/92, 236/104, and 213/102, with no evidence of timely reassessment or provider notification documented in the medical record. The provider only became aware of the elevated blood pressure by reviewing the electronic health record, not through direct communication from nursing staff. Interviews with nursing staff and the nurse practitioner confirmed that the expectation was for providers to be notified of out-of-range blood pressures and for such communication to be documented. The facility's policy required informing the provider of significant changes in a resident's condition, including clinical complications or the need to alter treatment. Despite this, there was no documentation that the provider was notified of the resident's elevated blood pressures, nor was there evidence of prompt reassessment following the abnormal readings.
Failure to Assess and Address Edema, Weight Gain, and Complete Physician Orders
Penalty
Summary
The facility failed to assess and address significant weight gain, edema, and to follow through with physician orders for a resident with multiple comorbidities, including stage III chronic kidney disease, diabetes, morbid obesity, and a cardiac murmur. The resident, who was cognitively intact, reported a recent hospitalization for high ammonia levels and expressed dissatisfaction that the facility did not identify the issue earlier. Despite a physician order for an ammonia lab test following her return from the hospital, there was no evidence in the electronic medical record that the test was completed, and staff were unaware of the order. Observations revealed the resident had 1-2+ pitting edema in her lower extremities and swollen hands, with a notable weight gain of over 22 pounds within approximately two months. Nursing staff and management were not aware of the weight gain or edema until prompted, and there was no documentation of reweighing, provider notification, or resident education regarding food and fluid intake as expected by facility policy. The care plan included daily foot inspections and lab monitoring for electrolyte imbalances, but these interventions were not effectively implemented.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with significant medical conditions, including Parkinsonism, scoliosis, and severe cognitive impairment, was not provided with appropriate preventative care and services for pressure injuries. Despite a Braden Scale assessment indicating a high risk for pressure ulcers, the resident's care plan did not reflect this risk, and there were no meaningful interventions tailored to her needs. Observations over two days showed the resident remained in the same position in bed for extended periods, with her legs elevated on pillows and her heels offloaded, but without regular repositioning. Multiple staff interviews revealed a lack of awareness and implementation of repositioning protocols. Certified Nursing Assistants (CNAs) reported either not seeing any skin issues or not having orders to reposition the resident, despite the Director of Nursing's expectation that all bedbound residents be repositioned every two hours. The resident herself reported discomfort and pain, rating it as 7 out of 10, and was observed with a large, blanchable, reddened/purple area on her coccyx. Staff only repositioned her after the area was noted, and there was no documentation of consistent repositioning prior to this. The facility's policy required the interdisciplinary team to develop a care plan with measurable goals and evidence-based interventions for residents at risk of pressure injuries. However, the care plan for this resident did not address her high risk status, and staff failed to implement routine preventative measures such as regular repositioning. This lack of adherence to both the care plan and facility policy led to the development of a significant pressure area and ongoing discomfort for the resident.
Failure to Identify and Address Foot Drop and Positioning Needs
Penalty
Summary
A resident with diagnoses including Parkinsonism, scoliosis, and cervical spondylosis with myelopathy was observed to have bilateral limited range of motion in her upper and lower extremities and required substantial to maximal assistance for bed mobility. Despite these conditions, there was no diagnosis of contractures or foot drop documented in her medical records, and her care plan did not address positioning or limited range of motion. Over multiple observations across two days, the resident was consistently found lying on her back in bed with her legs elevated on pillows and her left foot in a plantar flexion position, indicative of foot drop. Staff interviews revealed a lack of awareness regarding the resident's contractures or need for range of motion care, and no orders were in place for repositioning. Further observations noted that the resident remained in the same position for extended periods, and a large blanchable reddened/purple area was observed on her coccyx, with the resident reporting discomfort. The unit manager was unaware of any contractures, and the director of nursing only became aware of the foot drop after hospice staff assessed and documented it. The care plan lacked any focus on positioning or interventions for limited range of motion, and staff reported that such care would only be initiated if ordered by hospice or therapy.
Resident Found Restrained by Blanket Due to Staff Negligence
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse involving physical restraints. On the morning of October 15, 2024, a resident was found tightly wrapped in a blanket from the waist down, restricting movement. The staff member assigned to the resident's care had left the facility without notifying the nurse on duty and before the oncoming shift arrived. This incident was discovered by the oncoming Certified Nurse Aide (CNA) who found the resident unable to move without experiencing pain. The resident involved was admitted to the facility with Alzheimer's Disease, Dementia, and Anxiety, and was severely cognitively impaired with a BIMS score of 5. The resident was also incontinent and had a history of rejecting care and displaying behaviors toward others. The care plan required one to two staff members to check and change the resident's incontinence briefs. However, the resident was found wet, with the incontinence brief on backward, indicating a failure to provide appropriate care. Interviews with staff revealed that the CNA responsible for the resident during the night shift left early without completing proper shift change rounds. The CNA claimed the resident might have tangled herself in the blanket, but this was inconsistent with the resident's condition and the manner in which the blanket was wrapped. The facility's Director of Nursing and Nursing Home Administrator were informed of the incident, and an investigation was initiated immediately.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to maintain an environment free from potential accidents and hazards for several residents. Resident #23, who has severe cognitive impairment and relies on staff for all needs, was observed with her call light out of reach on multiple occasions, despite being capable of using it. This was against the facility's policy, which requires staff to ensure the call light is within reach during each interaction. Similarly, Resident #37, who has a history of falls and cognitive impairment, was found with her call light out of reach and her wheelchair unlocked, increasing her risk of falls. Resident #4, who has Alzheimer's and severe cognitive impairment, was observed struggling to free her wheelchair from a hoyer lift in a cluttered hallway, with staff passing by without offering assistance. This situation posed a significant risk of falls or injury. Resident #42, who is at increased risk for falls, was found without grip strips by her bed, contrary to her care plan. The grip strips had not been relocated after furniture was moved, and the room was cluttered, creating additional trip hazards. Residents #46 and #58, both with dietary restrictions and supervision needs, were observed eating independently without staff supervision in the dining room. This lack of supervision was contrary to their care plans and posed a risk of choking, especially since the Activity Director present was not certified to perform the Heimlich maneuver. The facility's dining policy did not specify the need for supervision of residents at risk for choking, indicating a gap in ensuring resident safety during meals.
Facility Cleanliness and Repair Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair, leading to potential contamination risks. During a tour, it was observed that the Beauty shop hair wash sink lacked proper backflow prevention, allowing the hose to drop below the overflow rim without an inline atmospheric vacuum breaker. In the 200 Hall linen closet, the open wire rack shelving had no bottom barrier, and the floor beneath was heavily accumulated with dust and paper trash debris. Similarly, the Garden utility room and janitor's closet had dust and debris accumulation, with the latter lacking a wasting tee to maintain the integrity of the hose bib vacuum breaker. In the 300 shower room, slings were improperly stored on the floor, with some portions dangling, which was acknowledged as incorrect by the Maintenance Director. The 300 clean linen closet also lacked bottom barriers on the wire rack, with dust and debris on the floor. Additionally, a large hole was found under the sink counter in the lakeshore dining room, which the Maintenance Director was unaware of due to being new to the facility. These observations indicate a failure to maintain cleanliness and repair, potentially leading to contamination of linens and domestic water.
Failure to Maintain a Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe and clean homelike environment for two residents, R42 and R23. R42, who is non-ambulatory and uses a motorized wheelchair, was observed to have a cluttered room with personal belongings spread across all flat surfaces, including an unoccupied bed. Despite being cognitively intact and expressing a desire to organize her belongings, R42 reported that staff had not offered assistance. The Director of Nursing acknowledged the clutter issue but was unaware of any care plan addressing it. The care plan only included an intervention to respect R42's personal space, implemented by social services, without addressing the clutter. No documentation was found in the electronic medical record or care conference summaries regarding the clutter or any staff education or assistance offered. R23, a resident with severe cognitive impairment and dependent on staff for all needs, was observed with laminated communication boards coated in a sticky substance similar to tube feed formula. These boards were repeatedly found in the same condition over several days. The Kardex for R23 indicated that she communicates using these picture boards, but there was no indication that staff addressed the cleanliness of these essential communication tools. The repeated observations of the sticky substance on the boards suggest a lack of attention to maintaining a clean environment for R23.
Failure to Monitor Bowel Preparation Leads to Missed Procedure
Penalty
Summary
The facility failed to properly administer and monitor a bowel preparation protocol for a resident, leading to the resident missing a scheduled colonoscopy appointment. The resident, who was cognitively intact and capable of making his own decisions, was given a bowel preparation regimen to follow, which included taking a series of pills. However, the resident was left to self-administer the medication without proper assessment or monitoring by the staff. On the day of the procedure, the resident woke up soiled and in a state of panic, as no staff had checked on him or assisted him in preparing for the appointment. The resident attempted to seek help from two CNAs, who were too busy to assist him. Consequently, the resident, feeling distressed and unsupported, left the building shoeless and soiled, and sat by the transport bus. The police were called to the scene, but the resident was calm upon their arrival. Despite the incident, there was no documentation in the resident's medical record regarding the monitoring of the bowel preparation, the resident's physical status, or any reminders given to the resident about the procedure. Additionally, there was no record of the incident being reviewed or discussed with the resident or staff. The facility's administration acknowledged that the resident was independent but stated that care would be provided if requested. However, the resident reported that no assistance was offered, and he was left to clean himself up. The administration also noted that the resident had a history of refusing the preparation or having the procedure canceled. Despite this, there was no care plan indicating that the resident should not be awakened in the morning, and the incident was not properly addressed or documented in the resident's care plan.
Failure to Maintain Range of Motion and Prevent Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate care to maintain and improve the range of motion and prevent skin breakdown for a resident with a severe contracture. The resident, who had a history of hemiplegia, hemiparesis, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy, and cognitive function issues, was observed multiple times with her left hand in a fist position, indicating a lack of proper range of motion exercises. The resident's care plan did not include interventions for maintaining the range of motion or promoting skin integrity for her left hand. Interviews with staff revealed that the resident previously used a splint, which was discontinued, leading to issues with skin irritation. A CNA reported the resident's hand condition, including pink skin, to a registered nurse, but the care plan still lacked specific interventions for the resident's left hand. Observations showed that the resident's hand could be partially opened, and a rolled washcloth was used to keep the hand dry and prevent further irritation. Despite these observations, the care plan and ADL care plan did not address the necessary interventions to maintain the resident's hand condition.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to complete a thorough assessment and develop an individualized care plan for a resident diagnosed with PTSD. The resident, who was not their own responsible party and had a legal guardian, was admitted with a history of PTSD, severe intellectual disabilities, legal blindness, hallucinations, and a personal history of childhood abuse. Despite these significant diagnoses, the facility's care plan did not include a focus on the resident's PTSD or any goals and interventions to address this condition. During an observation, the resident was seen becoming visibly upset and crying when a male visitor entered the room, indicating a potential trigger related to their history of abuse. The care plan did include an intervention specifying no male caregivers, but this was added 18 days after admission, and staff were not aware of the reason behind this intervention. The lack of awareness among staff about the resident's history of abuse and PTSD contributed to the deficiency in care planning. Interviews with the legal guardian and facility staff revealed a lack of information and understanding about the resident's needs prior to admission. The Director of Nursing acknowledged the oversight in assessing and care planning for the resident's PTSD, which was noted in the hospital discharge paperwork. This deficiency highlights the facility's failure to adequately address the resident's mental health needs and history of trauma, leading to an inadequate care plan and potential distress for the resident.
Failure to Provide Collaborative Hospice Care
Penalty
Summary
The facility failed to provide collaborative hospice care for a resident, resulting in the potential for unmet needs. The resident, who was not her own responsible party, had multiple diagnoses including hemiplegia, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy, and cognitive function issues following cerebrovascular disease. Despite being under hospice care, there was no clear documentation or communication regarding the hospice services being provided. A Certified Nurse Aide was unable to locate a hospice care calendar for the resident and was unaware of the specific care provided by hospice staff. Interviews with a Registered Nurse and Unit Manager revealed that they were not aware of any hospice care worker being present in the building and could not find any hospice schedule or notes for the resident. The Nursing Home Administrator later discovered that the hospice provider's access to the facility's electronic medical charting system was not functioning, which contributed to the lack of documentation. The hospice care plan for the resident only included a vague instruction to refer to the hospice provider with any changes in condition, without detailing the services to be provided. The hospice agreement with the facility required documentation of all services, which was not fulfilled in this case.
Infection Control Deficiency with Foley Catheter and Biliary Drain
Penalty
Summary
The facility failed to implement proper infection prevention measures for a resident with a Foley catheter and biliary drain. The resident, who had a history of hemiplegia, malnutrition, diabetes with neuropathy, and cognitive impairments, was observed with her urinary collection bag and biliary drain bag in contact with the floor. A certified nurse aide (CNA) acknowledged that the bags should not be on the floor but was unsure how to address the issue given the requirement for the bed to be in a low position. The CNA attempted to rectify the situation by placing a towel on the floor and then placing the bags on the towel, but inadvertently stepped on the towel multiple times during care. The resident's care plans for the biliary drain and indwelling suprapubic catheter did not provide specific instructions on the proper placement of drainage bags to prevent infection. The care plan for the biliary drain included monitoring for infection and emptying the bag every shift, while the catheter care plan instructed positioning the bag below the bladder level. However, there was no guidance on maintaining the bags off the floor while keeping the bed in a low position, contributing to the deficiency in infection control practices.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to monitor a diabetic resident's blood sugar levels while administering insulin, which could lead to unnoticed hyperglycemia and hypoglycemia. Resident #105, who was moderately cognitively impaired and had diagnoses including diabetes mellitus and congestive heart failure, was admitted to the facility. The resident's blood sugar checks were performed once daily in April 2024 but stopped from May 3, 2024, to May 9, 2024, despite the continuation of long-acting insulin administration. This lapse occurred after the discontinuation of short-acting insulin on May 1, 2024, which inadvertently stopped the associated blood sugar monitoring order. Interviews with facility staff revealed a communication breakdown between medical providers and nursing staff. Physician J intended for blood sugar monitoring to continue after adjusting the insulin orders due to low fasting blood sugar levels. However, the order for blood sugar checks was linked to the discontinued short-acting insulin, leading to the oversight. Nursing staff, including LPN H, expressed that blood glucose levels should be checked before insulin administration, and the former DON A acknowledged the communication issue and the importance of blood sugar checks as a vital sign, which did not require a physician's order.
Neglect Leading to Resident's Deterioration and Death
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in the resident's physical deterioration and subsequent death. The resident was admitted for short-term rehabilitation following a left arm fracture and a urinary tract infection. Upon admission, the facility identified a pressure injury on the resident's right heel but failed to follow hospital discharge instructions and physician's orders for wound care. This neglect led to the worsening of existing wounds and the development of new ones on various parts of the resident's body, including the right 5th toe, right heel, right lateral foot, right lateral lower leg, sacrum, coccyx, and thoracic spine. Additionally, the facility did not ensure the resident had adequate hydration and nutrition, and the resident was left in a wheelchair for an extended period, resulting in a fall and head injury. The resident was also placed in a room with a COVID-positive resident and subsequently contracted COVID-19. The resident was later admitted to the hospital with septic shock, malnutrition, significant weight loss, and multiple severe pressure injuries. The resident was placed on hospice care and died of sepsis. The facility's inaction included failing to notify the provider of the resident's wounds identified during the admission assessment, not ordering or initiating wound care treatments as per hospital discharge orders, and not scheduling a wound consult in a timely manner. The resident's care plan lacked interventions to prevent the worsening of pressure injuries and the development of new ones. The facility also failed to ensure the resident had access to fluids and food, leading to hypoglycemic events and dehydration. Despite multiple staff being aware of the resident's declining condition, no effective actions were taken to address the issues. The resident's care plan was not updated to reflect necessary interventions, such as elevating the left upper extremity to reduce swelling or ensuring the resident was assisted out of bed for meals. The facility's neglect extended to not performing regular skin assessments and not documenting changes in the resident's condition. The resident's pressure injuries were not adequately monitored or treated, and the facility did not follow its own policies and procedures for wound management and documentation. The resident's fall from the wheelchair was attributed to being left in an upright position for an extended period, and the care plan did not include interventions to prevent such incidents. The facility's failure to provide appropriate care and timely interventions led to the resident's severe decline and eventual death.
Failure to Provide Quality Care and Proper Documentation
Penalty
Summary
The facility failed to provide quality care to three residents, resulting in untreated sepsis and septic shock for one resident. Resident #17, a female with Huntington's disease, diabetes mellitus, and a gastrostomy tube, experienced multiple instances of inadequate care. Despite showing signs of distress such as dyspnea, diarrhea, and vomiting, there were significant gaps in documentation and communication with the provider. Missed doses of prescribed medication and delayed assessments contributed to her deteriorating condition, ultimately leading to a diagnosis of sepsis and septic shock due to a urinary tract infection and pneumonia upon her transfer to the emergency department. Resident #101, a male with cerebral palsy, epilepsy, and severe cognitive impairment, also received inadequate care. After a nurse observed a green, yellowish secretion from his penis, an antibiotic was prescribed. However, there was no follow-up documentation to monitor the effectiveness of the medication or the resident's condition. This lack of follow-up persisted for several days, indicating a failure to adhere to professional standards of care. Resident #126, a male with urinary retention, had orders for bladder scans and straight catheterization if the urine volume exceeded 350 ml. Despite bladder scan results showing volumes well above this threshold, there was no documentation of catheterization or the results of such procedures. This lack of documentation was confirmed by the Nursing Home Administrator, highlighting a significant lapse in the facility's adherence to prescribed medical orders and proper record-keeping.
Failure to Provide Adequate Supervision and Implement Care Interventions
Penalty
Summary
The facility failed to provide adequate supervision based on current medical concerns for two residents reviewed for falls, resulting in fractures for both. Resident #107, a male with a history of multiple falls and lower extremity weakness, was admitted to the facility following a hospital stay. Despite documented concerns about his mobility and need for assistance, the resident experienced two falls on the evening of his admission. The facility did not implement new interventions after these falls, and the therapy staff was not informed of the incidents. The resident was later found to have a right femoral neck fracture after being sent back to the emergency department for evaluation of hip pain. Resident #104, a female with severe cognitive impairment and a significant history of falls, sustained an unwitnessed fall in her room. Despite being documented as confused and having a high risk for falls, the resident was left unattended in a recliner after the fall. She was later diagnosed with a fractured distal left radius, a head contusion, and a neck sprain. The facility's failure to provide adequate supervision and implement appropriate interventions contributed to the resident's injuries. The facility also failed to implement documented care interventions for another resident, Resident #116. This resident, who had specific dietary and safety needs, was observed multiple times without the required fall mat in place and with her bed not in the low position. Additionally, the resident was provided with straws despite care plans and meal tickets indicating that straws should not be used. Staff members, including CNAs and kitchen staff, did not consistently follow the care plan, leading to potential safety hazards for the resident.
Failure to Ensure Timely Response to Call Lights and Accessibility of Fluids
Penalty
Summary
The facility failed to ensure that call lights were answered and resident needs were met in a timely manner, that call lights were within reach and accessible, and that fluids were available or within reach for six residents. Resident #127 reported that waiting an hour for the call light to be answered was not uncommon, leading to delays in receiving pain medication or fluids. Resident #100's DPOA indicated that call light wait times usually took 40-50 minutes, and no fluids were available in the room during an observation. Resident #101, who has severe cognitive impairment and cannot use his left arm, had his call light placed out of reach and out of sight, with no care plan intervention to accommodate his needs. Resident #104, who has severe cognitive impairment, was observed multiple times with fluids out of reach, and the family reported that staff did not frequently check on the resident. Resident #119 experienced delays in receiving assistance with incontinence care and was left waiting for staff to return to place her on the bedpan. Resident #116, who is moderately cognitively impaired, was observed multiple times with her call light out of reach and reported needing assistance with incontinence care. Staff interviews revealed that call lights were often left unanswered for hours due to staffing shortages, and some staff were observed using their phones instead of performing routine care. The facility's policy on call lights was not followed, contributing to the deficiencies observed.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in medications not being administered according to physician orders and outside of the ordered parameters. Resident #111, diagnosed with hypotension, had a physician order for Midodrine HCl to be administered three times a day with blood pressure assessments prior to each dose. However, out of 70 required assessments, only 40 were conducted, and the medication was held three times without proper documentation. Resident #112, diagnosed with hypertension, had a physician order for Isosorbide Mononitrate ER to be administered in the morning with blood pressure assessments prior to each dose. Out of 29 required assessments, only 10 were conducted, with two assessments on one day. Resident #113, also diagnosed with hypertension, had a physician order for Carvedilol to be administered twice a day with specific blood pressure and heart rate parameters. Despite low blood pressure readings, the medication was administered on two occasions. Resident #114, diagnosed with hypertension, had a physician order for Isosorbide Mononitrate ER to be administered in the morning with blood pressure assessments prior to each dose. Out of 29 required assessments, only 8 were conducted, with two assessments on one day. Interviews with facility staff revealed that nurses did not consistently follow physician orders for medication administration, often administering medications late and without assessing vital signs as required. The facility's policy on medication administration procedures emphasized the importance of reviewing the five rights of medication administration and obtaining necessary vital signs prior to administration. However, staff reported that the electronic health record system did not prompt them to assess vital signs, leading to non-compliance with physician orders. The nurse practitioner and licensed practical nurses interviewed expressed concerns about the lack of adherence to professional standards and the facility's medication administration policy.
Failure to Monitor and Assess Resident Positioning
Penalty
Summary
The facility failed to monitor and assess the positioning of a resident with severe cognitive impairment and multiple physical disabilities. The resident, who has cerebral palsy, epilepsy, paraplegia, and other conditions, was observed multiple times without protective boots, with feet rolled in and pressed against each other, and with a foley collection bag and tubing improperly positioned under his legs. These observations were made at different times throughout the day, indicating a consistent lack of proper positioning and monitoring by the staff. Additionally, the resident was observed in a broda chair with improper positioning, including being slid down in the chair, feet internally rotated and pressed together, trunk misaligned, and left buttock partially on the armrest. The Director of Therapy Services confirmed that the resident should not be positioned in such a manner. These findings highlight the facility's failure to provide appropriate care to maintain or improve the resident's range of motion and mobility, as required.
Failure to Maintain Accurate Controlled Substance Documentation
Penalty
Summary
The facility failed to maintain clear and concise controlled substance counts and accurately document the administration of controlled substances for four residents. For Resident #101, Phenobarbital and Gabapentin were not administered on specific dates, yet the Medication Administration Record (MAR) indicated they were. Similarly, Resident #122's Gabapentin administration was inconsistently documented, with discrepancies between the Controlled Substance Log and the MAR. Additionally, there were instances where doses were marked as administered in the MAR but not in the log, and vice versa. Resident #123's Norco administration on one date showed no documentation of wastage, despite the MAR indicating a refused dose. Resident #124's Gabapentin was also inconsistently documented, with the MAR showing administration on dates when the log did not. Interviews with Licensed Practical Nurses (LPNs) revealed that facility nurses did not follow standards of practice for narcotic administration, documentation, and storage. LPNs reported that nurses would share narcotic keys and sign out all controlled substances at the end of their shift rather than at the time of administration. This practice was confirmed by the Regional Director of Operations, who acknowledged the errors identified in the Controlled Substance Logs. The facility's policy on controlled substances, effective since 09/2018, mandates accurate inventory and immediate documentation of administered controlled substances. However, the facility failed to adhere to these procedures, leading to discrepancies in the administration records and logs. The Director of Nursing and the consultant pharmacist are responsible for maintaining compliance with federal and state laws regarding controlled medications, but the observed practices fell short of these requirements.
Failure to Follow Medication Storage Procedures
Penalty
Summary
The facility failed to follow established procedures regarding the storage of medication and controlled substances. During an observation, a medication cart outside of a resident's room contained seven loose pills in the bottom of the top drawer. The Director of Nursing (DON) confirmed that there should not be any loose pills in the medication carts and that there was no way to verify if these medications had been administered to the correct residents. Additionally, another medication cart designated as Lakeshore #1 contained two loose pills identified as Baclofen 20 mg and Eliquis 2.5 mg. An LPN stated that there was no way to know if these medications had been replaced and dispensed to the intended resident. Furthermore, on the Garden Unit, a medication cart contained five loose pills identified as hyoscyamine sulfate, quetiapine fumarate, Levothyroxine, Donepezil, and Haloperidol. The Unit Manager/LPN left the medication cart unlocked after the observation. The medication store room outside the Garden Unit was found unsecured and accessible without a code. Additionally, the refrigerator in the medication room outside the Garden Unit was unlocked, containing an unsecured bottle of liquid Lorazepam, a controlled substance. The facility's policy on the storage of medications, last revised on an unspecified date, mandates that medications and biologicals be stored safely, securely, and properly, with medication rooms, carts, and supplies locked when not attended by authorized personnel. The policy also requires that controlled substances requiring refrigeration be stored within a locked box inside the refrigerator. These observations indicate a failure to adhere to the facility's established procedures for medication storage and security.
Infection Control Deficiencies in Wound Care and Hygiene Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in one of two shower rooms reviewed and for four residents observed for skin and wounds. The deficiencies included improper handling of soiled linens, inadequate hand hygiene, and improper wound care techniques. Specifically, soiled linens were left in resident rooms and bathrooms, and staff did not perform proper hand hygiene or change gloves when required, leading to potential cross-contamination and infection risks for residents with pressure ulcers and other wounds. Resident #100 was observed being transferred to a shower room where a soiled towel and washcloth were present. The CNAs did not provide adequate peri-care or change gloves while handling soiled linens and applying cream to open areas on the resident's skin. Similarly, Resident #113 received wound care where the LPN used the same gauze pad multiple times, increasing the risk of infection. Resident #202 experienced cross-contamination during a dressing change when the LPN used the same gauze pad to clean both the anal area and an open wound. Resident #201's dressing change was conducted without proper hand hygiene and glove changes. The RN pressed on the wound bed with soiled gloves and covered an exposed wound with a contaminated bed sheet. The Director of Nursing confirmed that these practices were not in accordance with the facility's infection control policies, which require thorough hand washing and proper glove use to prevent the spread of infection.
Failure to Address and Resolve Grievances
Penalty
Summary
The facility failed to address and resolve grievances for a resident who required a colon cancer screening test. The resident, a female with dementia, had an order for the test that was initially placed two years ago. However, the facility made errors in submitting the specimen, leading to the cancellation of the test on two separate occasions. Despite multiple attempts and orders for the test, there was no follow-up or additional orders placed to ensure the test was completed. The resident's guardian reported the issue, but the facility did not take prompt action to resolve the grievance. Documentation revealed that the facility was aware of the ongoing concern but failed to take appropriate steps to address it. The Nursing Home Administrator indicated that the Director of Nursing was responsible for the follow-up, but the Nurse Practitioner reported not being notified of any concerns regarding the resident's laboratory or diagnostic testing requests. As a result, the resident's colon cancer screening test remained incomplete, and there was no documentation of any further attempts to collect the specimen or notify the appropriate medical personnel.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide care following the comprehensive care planned interventions and facility policy to prevent the development and worsening of avoidable pressure injuries for two residents. Resident #116, a moderately cognitively impaired female with muscle weakness, chronic pain, and dysphagia, was observed multiple times with her heels resting directly on a folded blanket or mattress, contrary to her care plan which required her heels to be elevated off the bed. Additionally, Resident #116 reported significant pain in her heels and buttocks, and stated she had not received incontinence care since early morning, despite her care plan indicating she required assistance with incontinence care and repositioning. The facility also failed to complete a Weekly Skin Sweep on 1/26/24 and did not notify her Durable Power of Attorney of the skin impairment identified on 1/29/24. Staff interviews revealed insufficient staffing to meet resident needs, including answering call lights and providing timely care. Resident #117, a female with muscle weakness, difficulty walking, and a history of falls, had a new vascular wound on her left lower leg. The wound was initially identified on 12/21/23, and a treatment recommendation was made to paint the wound with betadine once daily and leave it open to air. However, this treatment was not ordered or implemented until 1/4/24, resulting in the wound deteriorating from a scab to an open area. The Wound Consultant Physician Assistant was not aware that the treatment was not implemented until her next visit on 1/4/24. Staff interviews indicated that there were insufficient staff on the dementia unit to provide frequent repositioning, incontinence care, and activities of daily living. The facility's policies on Skin and Pressure Injury Risk Assessment and Prevention and Wound Treatment Management and Documentation were not followed. The policies required skin assessments upon admission and weekly thereafter, development of a relevant care plan with measurable goals, and timely implementation of wound treatments in accordance with physician orders. The facility failed to adhere to these policies, resulting in increased pain, skin impairment, and worsening of wounds for the residents involved.
Failure to Maintain and Store Respiratory Equipment Appropriately
Penalty
Summary
The facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for a resident, resulting in the potential for respiratory illness from cross-contamination. The resident, who was admitted with chronic respiratory failure, COPD, and dependence on supplemental oxygen, had nebulizer equipment with visible droplets resting directly on a bedside table without a barrier. Additionally, the oxygen tubing was not stored in a plastic bag when not in use, and the nasal cannula was placed on the handle of the wheelchair and on the resident's pillow instead of in a storage bag. There were no orders for cleaning and storage of the nebulizer equipment in the resident's Medication Administration Record (MAR). During an observation, a CNA was seen handling the resident's nasal cannula without following proper hygiene protocols. The CNA removed the nasal cannula and placed it on the resident's pillow during a transfer to the bathroom, then retrieved it with soiled gloves and placed it back in the resident's nose. The facility's policy required that nebulizer equipment be cleaned and stored in a plastic bag marked with the resident's name and date, but this was not followed. The Nurse Consultant confirmed that the expectation was for staff to clean nebulizer equipment and store oxygen equipment in storage bags.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program for a resident, resulting in the potential for antibiotic resistance. The resident, who had multiple diagnoses including psychomotor deficit following cerebral infarction, dementia, and Type 2 diabetes, was prescribed antibiotics without proper documentation or assessment. The resident's medical records did not reflect any signs or symptoms of infection prior to the initiation of antibiotic therapy, and there was no infection monitoring or user-defined assessments completed before starting the antibiotics. Additionally, the audiology consult that identified middle ear fluid was conducted 15 days before the antibiotics were started, and the attending physician or provider had not seen or assessed the resident before initiating the antibiotic treatment. The resident was prescribed Amoxicillin for an ear infection, but subsequent nursing progress notes and practitioner progress notes indicated that the antibiotics were also being used to treat a UTI and an infection in the left foot. The urine culture report did not meet the threshold for treatment, and there was no documentation of a risk versus benefit statement to justify the prescribed antibiotics. The resident's daughter expressed concerns about the resident's ability to take oral antibiotics due to swallowing difficulties, leading to the addition of an intramuscular antibiotic. However, the clinical record did not contain the required documentation to support these decisions. During an interview, the Nurse Practitioner (NP) and the Director of Nursing (DON) confirmed the lack of documentation related to infection tracking and the absence of a risk versus benefit statement. The NP admitted to prescribing a repeat urinalysis with culture and sensitivity after the course of antibiotics, but did not specify that it would only be done if symptoms persisted. The DON acknowledged that the culture results did not represent a treatable infection, highlighting the facility's failure to adhere to its Antibiotic Stewardship Program and proper infection control protocols.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and implement necessary interventions for pressure ulcers for two residents. Resident #13, who was admitted with a stage 4 pressure ulcer, diabetes, and paraplegia, reported that his pressure ulcer dressing was not replaced promptly after it came off during a shower. He also mentioned that dressing changes were often missed, and staff did not reposition him as required. The Treatment Administration Record (TAR) for October and November showed multiple missed dressing changes without any documented rationale or physician notification. Observations and interviews with staff confirmed inconsistencies in dressing changes and a lack of proper documentation and follow-up on missed treatments and resident refusals. The care plan for Resident #13 lacked specific interventions for repositioning and did not reflect the resident's needs accurately. Resident #10, who was admitted for wound care and therapy, reported that staff did not know how to perform her pressure ulcer dressing changes and failed to do them daily. The October TAR revealed that a dressing change was missed, and the Director of Nursing (DON) acknowledged a lack of follow-up on her transfer of care and insufficient wound care orders. The facility's policy on skin and pressure injury risk assessment and prevention was not adhered to, leading to inadequate care for Resident #10. Interviews with various staff members, including the Nursing Home Administrator, Social Worker, Unit Manager, and DON, highlighted communication gaps and a lack of consistent follow-up on resident concerns and refusals. The facility's failure to document refusals properly, reapproach residents, and notify physicians of missed treatments contributed to the deficiency in pressure ulcer care. The care plans for both residents were found to be inadequate, lacking specific interventions and updates to reflect their current needs and conditions.
Failure to Implement Documented Care Interventions
Penalty
Summary
The facility failed to implement documented care interventions for a resident with Huntington's Disease and dysphasia, who had severe cognitive impairment and relied entirely on staff for all activities of daily living. Despite a physician's order for NPO (nothing by mouth), a handled drinking cup of water was observed within the resident's reach. Additionally, a Certified Nurse Aide (CNA) repositioned the resident without a second staff person assisting, contrary to the care plan that required a two-person assist for bed mobility. The CNA also left the resident unattended in a high bed position without the call light in reach while exiting the room to gather supplies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices in one of two shower rooms and for four residents observed for skin and wounds. Specifically, staff did not follow proper procedures for handling soiled linens, performing hand hygiene, and providing peri-care. For example, a CNA did not provide incontinent care before applying a clean brief to a resident, leaving the skin exposed to moisture and at risk for infection. Additionally, soiled linens were improperly handled in the shower room, and a transfer sling was placed on top of soiled linens, further risking cross-contamination. In another instance, a CNA and an LPN failed to change gloves and perform proper hand hygiene while providing wound care to residents. One resident with a stage 2 pressure ulcer had the same part of a gauze pad used multiple times over the wound area, and another resident with a stage 4 pressure ulcer had a gauze pad used to clean around the anus and then over the wound, leading to cross-contamination. Additionally, a resident with two pressure injuries had a dressing change performed by an RN who did not change gloves or wash hands adequately, and the wound bed was covered with a contaminated bed sheet while obtaining supplies. The Director of Nursing acknowledged that the observed practices did not align with the facility's infection control policies. The DON confirmed that gloves should have been discarded along with soiled dressings, hands should have been thoroughly washed, and wounds should not have been pressed with soiled gloves. The DON also noted that wounds should be covered with a clean covering while obtaining dressing supplies, and hand washing should be performed according to the facility's policy.
Failure to Provide Scheduled Showers and Maintain Hygiene
Penalty
Summary
The facility failed to provide showers for two residents, Resident #2 and Resident #12, as per their care plans. Resident #12, who has diagnoses of hemiplegia, hemiparesis, and dementia, was observed with oily, matted, and tangled hair, indicating a lack of proper hygiene. The resident's care plan specified showers on Friday mornings and Tuesday evenings, but records showed only one shower and five bed baths over a specified period, contrary to the resident's preference for showers to wash her hair. The Director of Nursing acknowledged the issue and mentioned efforts to address staff performance and supervision. Resident #2, who has multiple diagnoses including hepatic encephalopathy, hemiplegia, and diabetes with neuropathy, reported not receiving a shower for a couple of weeks and expressed frustration over lying on dirty sheets. The resident's care plan indicated showers on Monday and Thursday mornings, but documentation failed to reflect any showers or baths provided in the last 30 days. The resident stated that she had repeatedly asked for showers and clean sheets but was ignored. The Unit Manager confirmed the lack of documentation and acknowledged the resident's complaints about not receiving showers and having dirty sheets. Interviews with staff revealed inconsistencies in the documentation and provision of showers. A CNA responsible for showers explained the process but admitted that bed sheets should be changed with every shower or bath. The Unit Manager admitted that the resident's records did not show any showers being offered or provided and confirmed that the resident had requested clean sheets, which were not changed until the surveyor's visit. The facility's failure to adhere to the care plans and properly document care resulted in the residents not receiving the necessary hygiene care, impacting their dignity and well-being.
Failure to Follow Feeding Tube Policies and Best Practices
Penalty
Summary
The facility failed to follow policies and best practice standards for a resident with a feeding tube, resulting in potential issues with nutrition, hydration, and equipment contamination. The resident, a female with Huntington's Disease and severe cognitive impairment, had specific orders for tube feeding and water flushes. However, observations revealed discrepancies such as incorrect water flush rates, lack of labeling on equipment, and the use of disposable items beyond their recommended time limits. Additionally, a disposable declogger was found unwrapped and contaminated on the resident's bedside table. Further observations showed that a CNA placed the tube feed on hold without notifying a nurse, contrary to facility policy. Interviews with staff, including an LPN and the Director of Nursing, confirmed that CNAs are not permitted to handle tube feed pumps and should notify a nurse for such tasks. The facility's policy and manufacturer guidelines for the care and treatment of feeding tubes were not adhered to, as disposable equipment was not replaced daily, and enteral formula, medications, and flushes were not administered per physician's orders.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to follow procedures for administering and documenting the use of controlled substances for one resident, resulting in the potential for medication diversion and the resident not receiving physician-ordered pain medications as prescribed. The resident, a male with several pain-related conditions including migraines, trigeminal neuralgia, polyneuropathy, knee pain, and other chronic pain, had an order for Morphine Sulfate 15 mg IR to be taken every 4 hours as needed for pain management. However, discrepancies were found between the controlled substance record (CSR) and the electronic medication administration record (Emar) for multiple dates in October and November 2023, where the medication was signed out on the CSR but not documented as administered on the Emar. During interviews, the Director of Nursing (DON) and a Registered Nurse (RN) confirmed the discrepancies and acknowledged that both the CSR and Emar must be filled out accurately when dispensing controlled substances. Specific instances included multiple dates where Morphine Sulfate was signed out on the CSR but not recorded on the Emar, indicating a failure to document the administration of the medication properly. This failure to follow protocol was acknowledged by the DON as not being the standard of practice for the facility.
Failure to Maintain Locked Treatment Carts
Penalty
Summary
The facility failed to maintain locked treatment carts, resulting in the potential for accidental ingestion and misappropriation of physician-ordered treatments. During an observation on 11/28/23 at 8:50 AM, a treatment cart located in the short hall, outside the garden unit and near the garden unit sign, and next to the exit door, was found unlocked and unattended. This cart contained prescription medications such as Diclofenac and Triamcinolone, as well as over-the-counter (OTC) medications like antifungal cream and zinc oxide. Another observation on the same day at 9:10 AM revealed that a treatment cart located on the garden unit was also unlocked and unattended, containing prescription medications including Diclofenac and Ketoconazole, OTC medication hydrocortisone cream, and two bottles of bug spray: Off and Cutter. Registered Nurse (RN) T confirmed that treatment carts were supposed to be locked when unattended during an interview at 9:15 AM on the same day. Further observations on 11/28/23 at 10:00 AM showed that a treatment cart located off the main hall, next to the crash cart, was unlocked and unattended. This cart contained prescription medications such as Diclofenac gel 1%, Triamcinolone 0.1%, Miconazole 2% cream, and OTC medication hydrocortisone cream 1%. Another observation on 11/30/23 at 7:25 AM found the treatment cart located on the short hall, outside the garden unit and near the garden unit sign, and next to the exit door, was again unlocked and unattended. The facility's policy on the storage of medications, last revised in August 2020, states that medication rooms, carts, and supplies should be locked when not attended by authorized personnel.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to respond to call lights in a timely manner for three residents, leading to unmet needs and discomfort. Resident #13, who has a stage 4 pressure ulcer, diabetes, and paraplegia, reported that staff would turn off his call light without addressing his needs, such as repositioning, getting water, or emptying his colostomy bag. The call light log showed instances where the call light was on for up to 1 hour and 30 minutes, indicating significant delays in response. The Nursing Home Administrator (NHA) was aware of the issue but did not document any grievances, believing the matter was resolved after speaking with the resident. Resident #19, who has hemiplegia, vascular dementia, and other conditions, was observed waiting over 9 minutes for his call light to be answered. When staff finally responded, they did not assist him with his request to make his bed, leaving him in a soiled and unmade bed. The resident expressed frustration over the long wait times for assistance. Similarly, Resident #20, who is legally blind and has multiple chronic conditions, waited over 26 minutes for her call light to be answered. She needed coffee and had been waiting for over an hour for staff to bring her more. Her care plan emphasized the need for prompt response to her call light, which was not met. Observations revealed that staff were not attending to residents' needs promptly, as evidenced by the call lights being on for extended periods while staff were heard laughing in the nurse's office. This lack of timely response to call lights resulted in residents' needs not being met, causing discomfort and potential health risks. The facility's failure to address these issues adequately was noted in the report.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances for a resident with significant medical needs, including stage 4 pressure ulcers, diabetes, and paraplegia. The resident, who is cognitively intact, reported that his pressure ulcer dressing came off during a shower and was not replaced until the following day. He also expressed concerns about the timing and frequency of his dressing changes, which were often missed, and the lack of response to his call light. Despite reporting these issues to the administration, there was no documented follow-up or resolution of his grievances. Interviews with staff revealed inconsistencies in the care provided to the resident. The Licensed Practical Nurse (LPN) and Social Worker (SW) acknowledged the resident's complaints but did not have documented evidence of addressing them. The Nursing Home Administrator admitted to being aware of the resident's concerns but did not document any grievances or resolutions. The Treatment Administration Record (TAR) showed multiple missed dressing changes without any documented rationale or physician notification. Additionally, the call light log indicated long response times, further highlighting the facility's failure to meet the resident's needs.
Resident Restrained with Bed Sheets for 10 Hours
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints, resulting in the resident being unable to move or use her call light for approximately 10 hours. The resident, who was severely cognitively impaired with diagnoses including Alzheimer's Disease and dementia, was found wrapped tightly in her bed sheets, restricting her movement. This incident was discovered by a CNA during morning care, who then alerted a nurse to assist in freeing the resident from the sheets. The resident expressed confusion and distress over the situation. The CNA responsible for the night shift admitted to wrapping the resident tightly in sheets to prevent her from ripping off her brief, a practice he claimed to have been trained to do. However, the Nursing Home Administrator (NHA) found no evidence that this was a standard practice or that other residents had been similarly restrained. The NHA concluded that the CNA's actions were not in line with facility policy and constituted abuse and neglect. The facility's investigation led to the termination of the CNA for abuse and neglect. The facility's policies on a restraint-free environment and abuse, neglect, and exploitation were reviewed, confirming that the CNA's actions were deliberate and resulted in unreasonable confinement of the resident. The incident was documented in the resident's Alleged Abuse Incident Report, and the CNA's termination was formalized in a letter citing the investigation's findings.
Inadequate Incontinence Care Leading to Skin Issues
Penalty
Summary
The facility failed to provide adequate toileting and incontinence care for a resident with severe cognitive impairment, hemiplegia, diabetes, and dementia. The resident was observed in the dining room for several hours without being toileted, and when incontinence care was finally provided, her brief was found to be saturated with urine. The resident had a large, macerated area on her buttocks with pink un-blanchable skin, indicating a lack of timely care. The CNA initially reported that the resident was last toileted at 11:00 AM but later changed the statement to before 10:00 AM, and it was found that the care was not charted properly. Incontinence charting revealed that the resident was often provided care only twice or three times a day, with long intervals between care sessions. The resident's care plan indicated that she required regular checks and changes for incontinence, but no specific frequency was documented. Skin assessments over the month showed a progression of skin issues, culminating in a Stage 1 pressure ulcer on the resident's right buttock. The DON stated that residents should be checked and changed every two hours, but this standard was not met for the resident in question. The lack of consistent and timely incontinence care led to the resident developing significant skin issues, highlighting a deficiency in the facility's care practices.
Failure to Maintain and Store Respiratory Equipment Appropriately
Penalty
Summary
The facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for Resident #108, who had chronic respiratory conditions including chronic respiratory failure with hypoxia and Chronic Obstructive Pulmonary Disease (COPD). The resident's care plan included specific instructions for oxygen therapy and equipment maintenance, but these were not followed. During an observation, the nebulizer equipment was found with visible droplets and resting directly on a bedside table without a barrier. Additionally, the oxygen tubing was not stored in a plastic bag when not in use, and the nasal cannula was improperly handled by a Certified Nurse Aide (CNA) who did not change gloves after handling soiled items before placing the cannula back in the resident's nose. The facility's policy required that nebulizer equipment be rinsed, disinfected, and stored in a plastic bag marked with the resident's name and date. However, there were no orders for cleaning and storage of the nebulizer equipment in the Medication Administration Record (MAR). The Nurse Consultant confirmed that the expectation was for staff to clean nebulizer equipment and store oxygen equipment in storage bags, which was not adhered to in this case. This failure resulted in the potential for respiratory illness from cross-contamination for Resident #108.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program for one resident, resulting in the potential for antibiotic resistance. The policy for the Antibiotic Stewardship Program, last reviewed in January 2023, outlines that the Infection Preventionist, with oversight from the Director of Nursing, is responsible for leading the program. The program includes protocols for antibiotic use and a system to monitor antibiotic use. However, these protocols were not followed for Resident #100, who was admitted with multiple diagnoses including psychomotor deficit following cerebral infarction, dementia, and Type 2 diabetes. The resident was prescribed antibiotics without proper assessment or documentation of infection monitoring prior to the start of antibiotic therapy. The resident's medical records did not reflect any signs or symptoms of infection, and the attending physician or provider had not assessed the resident before initiating the antibiotic treatment. Additionally, the urine culture results did not meet the threshold for treatment, yet the resident continued to receive antibiotics for various infections, including an ear infection, UTI, and a foot infection. The Nurse Practitioner involved did not document a risk versus benefit statement to justify the prescribed antibiotics and failed to follow the facility's protocol for repeat urinalysis only if symptoms persisted. The Director of Nursing confirmed the lack of documentation related to infection tracking for the resident prior to the start of antibiotics.
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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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