Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Hancock, Michigan.
- Location
- 1400 Poplar Street, Hancock, Michigan 49930
- CMS Provider Number
- 235552
- Inspections on file
- 27
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
The facility did not employ a certified dietary manager or certified food service manager to oversee the food service department, as required by the facility's job description and the FDA Food Code. The individual promoted to Dietary Manager had not obtained the necessary certification, and this was acknowledged by facility leadership.
Surveyors identified deficiencies in food storage and dietary staff competency, including undated and expired food in the resident refrigerator, improper storage of deli meat above fresh produce, and staff uncertainty regarding food safety protocols. The NHA acknowledged issues with food dating and staff skills.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not have a licensed NHA overseeing daily operations for a period of time, with the DON managing all responsibilities in the absence of an administrator. The previous NHA's license remained posted despite her departure, and a new NHA was only hired on the day of the survey.
The facility did not implement or maintain an effective QAPI program, as evidenced by the absence of data collection, performance improvement projects, action plans, and regular team participation. The DON reported no ongoing QAPI activities and expressed uncertainty about the program's purpose, while the NHA and IP were not present at a recent QAPI meeting.
The facility did not establish priorities, develop action plans, or analyze data for its QAPI program. The DON reported no ongoing PIPs, no data collection, and no QAPI activities, and expressed not understanding the QAPI program's purpose, despite facility policy requiring a comprehensive, data-driven approach.
The QAPI committee did not meet quarterly as required and lacked attendance from the NHA and an Infection Preventionist, as the facility did not have one. Sign-in sheets confirmed missed meetings and absent required members, contrary to facility policy.
The facility did not follow its antibiotic stewardship policy, as multiple residents received antibiotics without consistent use of McGeer's Criteria or other accredited standards. The DON, acting as Infection Control Preventionist, acknowledged that antibiotics were sometimes prescribed based on clinical judgment rather than established protocols, and lacked the required training certificate. Documentation showed that antibiotic use was not accurately tracked or reviewed as required by facility policy.
The facility did not assign a qualified infection preventionist to oversee the infection prevention and control program, resulting in a lack of designated responsibility for infection control practices.
A resident with severe cognitive impairment, dysphagia, and a feeding tube did not have a person-centered care plan addressing the feeding tube or related interventions. Staff interviews confirmed the resident had a history of aspiration pneumonia and multiple hospitalizations, but the required care planning was not completed or updated as per facility policy.
A resident who required assistance with bathing and shaving did not receive a shower or grooming services for an extended period, despite being cognitively intact and expressing a desire for care. Staff interviews and documentation confirmed that scheduled ADL care was not provided as required, resulting in unmet care needs.
A resident with chronic respiratory conditions received oxygen therapy without proper humidification and with tubing that had not been changed according to facility policy. Observations showed an empty humidification bottle and outdated tubing, and the resident reported nasal discomfort. Staff interviews confirmed that the equipment was not maintained as required by policy.
Two residents experienced medication administration errors when an RN failed to properly prime an insulin pen according to manufacturer instructions and left a prepared dose of Miralax unattended without confirming ingestion or the resident's ability to self-administer. These actions resulted in a medication error rate above 5%, contrary to facility policy and best practices.
The facility did not ensure that two residents' responsible parties were informed about the purpose of binding arbitration agreements or their right to refuse, as required by facility policy. In both cases, the agreements were signed before responsible parties were designated, and the agreements were not reviewed with those parties afterward.
A resident with a history of falls and multiple medical conditions experienced several recent falls while attempting to self-transfer, but the care plan interventions were not updated to reflect these incidents or to include additional preventative measures. The DON confirmed that care plan revisions were not completed as required, citing recent staff changes as a contributing factor.
The facility's call light system was found to be non-operational for several residents, leading to delays in emergency care. A resident experienced a significant delay in assistance due to a malfunctioning call light, and staff confirmed ongoing issues with the system, including frayed cords and malfunctioning bulbs. Despite audits and replacements, the system continued to fail without a clear pattern.
A resident's dentures were reported missing shortly after admission, and the facility failed to provide the resident with information on facility rules and denture policies upon admission. The admission paperwork was completed only after the dentures were lost, and the facility's policies on lost or damaged property were not provided to the resident or their representative in a timely manner.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant delay in receiving necessary medical attention due to the facility's failure to respond promptly to a change in condition. Despite clear signs of distress and a request for hospital transfer, the attending RN delayed action to complete routine tasks, resulting in a delayed transfer and treatment. The facility's lack of effective monitoring and communication contributed to the deficiency.
The facility failed to monitor and document resident weights, resulting in significant weight loss for a resident with severe cognitive impairment and health issues. Admission weights were not obtained for two residents, and weekly weights were missing for another. The facility's weight monitoring policy was not followed, as confirmed by the DON.
The facility failed to implement a comprehensive infection control program during a COVID-19 outbreak, resulting in 40 out of 45 residents contracting the virus, with one death and multiple hospitalizations. The facility did not conduct adequate infection surveillance or implement effective transmission-based precautions. Staff inconsistently wore PPE, and there was a lack of proper signage and isolation measures. Additionally, the facility failed to implement a water management program and did not properly transport and sort linens, contributing to the sustained transmission of COVID-19.
The facility was found to have numerous maintenance and cleanliness issues, including stained carpets, broken furniture, and unsafe gaps in bed frames. A resident's room had a strong urine odor and split flooring seams, while another had a leaky ceiling. Maintenance staff acknowledged these issues, and the Nursing Home Administrator recognized the facility's failure to provide a safe and homelike environment.
The facility failed to ensure that two CNAs completed their annual competency training, as required. Interviews with the DON and the Human Resources/Business Office Manager revealed that the competency records were missing, and the NHA confirmed the absence of a policy on competency training. The Facility Assessment indicated that nursing staff should complete a competency checklist annually.
The facility did not conduct performance reviews for five CNAs within the required 12-month period. Personnel records showed that CNAs hired between 2016 and 2023 had not been evaluated. The HR/Business Office Manager could not provide the evaluations, and the NHA confirmed the absence of a policy for staff performance reviews.
The facility did not include resident census information on the Nursing Department Daily Staffing sheets, which are essential for calculating appropriate staffing levels. This issue was identified during a review of staffing hours, revealing missing census data on several dates. The Nursing Home Administrator acknowledged the oversight, admitting the sheets were not completed correctly, contrary to the facility's policy requiring the inclusion of current resident census.
The facility failed to adhere to food safety standards, with expired and unlabeled food items found in storage, unsanitary conditions in freezers and an ice machine, and a dishwasher that did not properly sanitize items. These deficiencies posed a risk of foodborne illness to residents.
The facility did not complete a comprehensive assessment to identify necessary resources for resident care, lacking training in key areas like ethics, communication, and infection control. Interviews with the DON and NHA revealed unawareness of required training components, and the Facility Assessment failed to evaluate the training program to meet staff and volunteer needs.
The facility failed to accurately report Payroll Based Journal (PBJ) information to CMS, leading to incorrect staffing level data. A review of the CMS PBJ Staffing Data Report for fiscal year Quarter 2 of 2024 showed excessively low weekend staffing on several dates. The Nursing Home Administrator (NHA) was unaware of the issue, suggesting possible data entry errors. Facility policy requires quarterly submission of accurate staffing data, with the NHA responsible for validation and corrections.
The facility failed to implement and monitor an antibiotic stewardship program, as the DON/IP did not maintain current listings or track antibiotic use. There was no documentation of residents receiving antibiotics, and the monthly infection summary lacked reports on infection data or antibiotic stewardship. These deficiencies were not reported to the QAPI meeting, violating facility policies.
The facility failed to educate and offer COVID-19 vaccinations to its staff, increasing the risk of infection spread. The DON admitted no education or vaccine offerings had been made, and the NHA confirmed the inconsistency. An RN reported not receiving education or vaccine offers in nearly two years. Facility policies required education and vaccine offerings per CDC guidelines, but these were not followed.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety risks for residents. A significant gap was found between a mattress and footboard, exceeding safety standards. Interviews revealed a lack of documentation for bed measurements, indicating inspections were not conducted. The facility's policy mandates regular inspections, but no records were found, posing a risk of injury to residents.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential zones of entrapment for residents. A large gap was found between a resident's bed mattress and footboard, which was outside the acceptable measurement for safety. Interviews revealed a lack of documentation for bed measurements and inspections, with staff confirming that such tasks had not been performed since the previous Maintenance Director's departure. The facility's policy requires regular inspections to prevent entrapment, but this was not adhered to, posing a risk to residents.
A facility failed to provide a resident with the prescribed minced and moist diet, serving diced turkey instead, which was inappropriate for the resident's dysphagia condition. Additionally, 46 residents received less protein than required due to incorrect portioning of a turkey casserole. The facility's diet manual was outdated, lacking current IDDSI standards.
A facility failed to provide written transfer notification to a resident and their representative when the resident was transferred to the hospital for nausea, vomiting, and uncontrolled pain. The Regional Clinical Consultant RN was unaware of the requirement, and the Nursing Home Administrator confirmed that the transfer form was not given or mailed to the resident or their representative.
A facility failed to provide proper wound care and infection control for a resident with a history of stroke and hemiplegia. The RN did not follow physician orders or infection control practices, using contaminated gloves and failing to apply the correct dressing. Additionally, a CNA was improperly instructed to apply a wound dressing, which is outside their scope of practice. The facility's policy requires licensed nurses to perform wound care, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment and legal blindness suffered a hip fracture after an unwitnessed fall in a facility. The resident's care plan lacked interventions for her visual impairment, and frequent checks were not implemented despite her increased fall risk and unfamiliarity with the environment. Limited staff availability and a closed door due to COVID-19 isolation further contributed to the delay in assistance.
The facility did not ensure that all staff received training on resident rights, as required by its policy. A review revealed that two CNAs hired in late 2022 had not completed this training. The Facility Assessment also lacked a requirement for such training, potentially affecting the rights of all 45 residents.
The facility failed to provide QAPI training to all staff, as evidenced by a CNA hired in 2022 not receiving the training. The facility's assessment lacked a requirement for QAPI training, and no QAPI policy was provided to the surveyor. This deficiency could lead to unmet care needs due to an ineffective performance improvement program.
The facility failed to provide mandatory infection control training for a CNA hired in March 2023, as required by its infection prevention and control program. This deficiency was identified during a review of training logs and the facility's assessment, which lacked a requirement for such training. The oversight had the potential to spread diseases among all 45 residents.
The facility failed to ensure two CNAs received the required 12 hours of annual in-service training, with one completing only 10 hours and the other 11.75 hours. The Human Resource/Business Office Manager noted the training requirement is based on hire date, and the NHA admitted to a lack of communication about training requirements, relying on a vendor-provided online system. This oversight potentially affected care for all 45 residents.
A resident was discharged to his home without notifying family members, without provision of home health services, and without necessary medical equipment and supplies. This led to emotional distress and a return to the hospital due to unaddressed care needs. The discharge was forced due to behavioral issues, but there was no consistent documentation of these behaviors, and the family was not given a choice in the discharge decision.
A resident with multiple medical conditions was discharged due to behavioral issues without a 30-day written notice to the resident, their representative, the Ombudsman, and the State Agency. The facility staff admitted to not following proper procedures, and the resident's family was left without necessary support.
A resident with complex medical conditions was inappropriately discharged without proper planning and support, leading to emotional distress and potential harm. The facility failed to provide necessary home health services, medical equipment, and proper communication with the resident's family and DPOA.
The facility failed to report timely an allegation of misappropriation of narcotics for a resident with neurocognitive disorder. Despite receiving a complaint about the resident's medication being tampered with, the facility did not report it to the State Agency as required by their policy. The internal investigation was incomplete and lacked proper documentation.
The facility failed to conduct a thorough investigation into an allegation of medication tampering for a resident with neurocognitive disorder. The investigation lacked proper documentation and witness statements, and the medication was destroyed without adequate evidence.
Lack of Certified Dietary Manager in Food Service Department
Penalty
Summary
The facility failed to employ a certified dietary manager or certified food service manager to oversee the food service department. Interviews with the Business Office Manager/Human Resources Manager revealed that the individual promoted to Dietary Manager had not obtained the required certification since their promotion. Review of the facility's job description for the Dietary Manager confirmed that certification was a stated requirement for the position. The Nursing Home Administrator acknowledged that the Dietary Manager did not meet the qualifications outlined in the job description. The report references the FDA Food Code, which requires the person in charge of food service operations to demonstrate knowledge of foodborne disease prevention and to be a certified food protection manager through an accredited program.
Deficient Food Storage and Dietary Staff Competency
Penalty
Summary
The facility failed to ensure that dietary staff possessed the necessary competencies and skills to safely and effectively manage food and nutrition services. During observations, surveyors found two small containers of food in the resident refrigerator labeled with a resident's name but lacking dates indicating when the food was brought in or a use-by date. Additionally, four containers of applesauce with a use-by date that had already passed were found in the same refrigerator. Dietary staff interviewed claimed that all items were checked and labeled, but this was contradicted by the surveyor's findings. One dietary staff member was also unsure of the required temperature for serving resident food. Further observations revealed two opened packages of deli meat placed on a wet tray in the resident refrigerator, with an opened box of apples stored directly underneath, creating a risk of cross-contamination. When questioned, a dietary staff member acknowledged the improper storage but stated they would not discard the apples, indicating a lack of authority or initiative. Another staff member admitted that dates on food items in storage areas were not routinely checked. The Nursing Home Administrator confirmed concerns regarding food dating and staff competency in dietary services.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Employ Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to employ a licensed Nursing Home Administrator (NHA) to oversee its day-to-day operations, as required by federal and state regulations. According to interviews, the Director of Nursing (DON) confirmed that there was no NHA present and that she was managing all facility operations. The Business Office Manager/Human Resource Manager stated that the NHA had been absent since May, and a new NHA was scheduled to start the following day. During the survey, it was observed that the previous NHA's license was still posted in the hallway, despite the former administrator confirming she had not been present since May and was unaware her license remained displayed. Review of the employee list indicated that the new NHA was only hired on the day of the survey, confirming a period without a licensed administrator in the facility.
Failure to Implement and Maintain QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective and comprehensive Quality Assurance Performance Improvement (QAPI) program that addresses the full range of services provided. During interviews, the DON stated that during a recent QAPI meeting, no topics were discussed as the full team was not present, with both the NHA and IP absent. The NHA reported that the DON supervised the QAPI program, while the DON admitted that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess problems, and had no action plans or ongoing QAPI activities. There was also no feedback, analysis, or tracking for the QAPI program, and the DON expressed a lack of understanding regarding the purpose of QAPI. Review of the facility's policy confirmed the requirement for a data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.
Failure to Implement and Operate QAPI Program
Penalty
Summary
The facility failed to establish priorities for improvement activities, develop and implement action plans, and review or analyze data collected under its Quality Assurance Performance Improvement (QAPI) program. During an interview, the DON stated that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess for problems, and had no action plans or ongoing QAPI activities. The DON also expressed a lack of understanding regarding the purpose of the QAPI program. Review of the facility's policy confirmed that it requires the development and maintenance of a comprehensive, data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.
QAPI Committee Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with all required committee members. Review of QAPI sign-in sheets showed that a meeting was held on 5/15/25, but the Nursing Home Administrator (NHA) and the Infection Preventionist did not attend. Additionally, there were no QAPI meetings held in April or June of 2025. During an interview, the Director of Nursing (DON) confirmed that the NHA did not attend the meeting and that the facility did not have an Infection Preventionist. The facility's policy requires the QAPI committee to include the DON, Medical Director or designee, three other staff members (including the administrator), and the infection control and prevention officer, and to meet at least quarterly. These requirements were not met, affecting all 38 residents in the facility.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize its antibiotic stewardship program as outlined in its own policy, resulting in inaccurate monitoring of antibiotic use for all 38 residents. Review of the Infection Prevention and Control binder showed that multiple residents who had taken antibiotics during the look-back period were marked as not meeting the criteria for antibiotic use on tracking sheets, despite the facility's protocol requiring the use of McGeer's Criteria. The policy mandates that the Infection Preventionist, with oversight from the DON, coordinates stewardship activities, maintains documentation, and ensures protocols are followed, including the use of McGeer's Criteria to define infections and the review of antibiotic orders for appropriateness. During an interview, the DON, who also served as the Infection Control Preventionist, admitted that neither she nor the physicians consistently used McGeer's Criteria or any other accredited antibiotic criteria when prescribing antibiotics. Instead, decisions were sometimes based on clinical experience and observed symptoms, even when residents did not meet established criteria. The DON also lacked the required Infection Control Preventionist training certificate. The facility's policy further requires regular monitoring, documentation, and review of antibiotic use, as well as annual education for nursing staff, but these processes were not consistently followed, as evidenced by the documentation and interview findings.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist responsible for the infection prevention and control program. This omission indicates that the required oversight and management of infection control practices were not assigned to a qualified individual as mandated.
Failure to Develop and Implement Person-Centered Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a male resident who was admitted with diagnoses including unsteadiness on his feet and dysphagia. The resident was severely cognitively impaired, as indicated by a BIMS score of 0 out of 15, and had a feeding tube due to difficulty swallowing and refusal to eat or drink. Despite these significant care needs, a review of the resident's care plan revealed that there was no focus area or interventions documented for the feeding tube. Interviews with staff confirmed that the resident had a history of aspiration pneumonia and multiple hospitalizations, yet the necessary care planning was not completed. Further interviews with the DON revealed an awareness that care plans were not being developed, implemented, or revised as required. The facility's policy mandates the creation of a baseline care plan within 48 hours of admission, including all necessary interventions and measurable goals, and requires ongoing updates based on changes in the resident's condition. However, these procedures were not followed for this resident, as evidenced by the lack of a person-centered care plan addressing the feeding tube and related risks.
Failure to Provide Timely ADL Care: Bathing and Grooming
Penalty
Summary
A deficiency was identified when a resident who required partial to moderate assistance with bathing and set up or clean-up assistance for shaving did not receive these services as needed. The resident, who was cognitively intact, reported not having had a shower in two weeks and not being offered a shower on the morning of observation. The resident also expressed discomfort due to long facial whiskers and disheveled hair, stating a desire to be shaved and to have a haircut. Observations confirmed the resident remained unshaved and unkempt over multiple days. Interviews with facility staff, including the DON and a CNA, revealed that showers and shaving were scheduled weekly, typically on the same day. However, review of the CNA shower log showed the resident had not received a shower since a specific date and had not refused care. The resident's care plan indicated a need for one-person assistance with showers. Facility policy required provision of ADL care, including bathing and grooming, but this was not followed for the resident in question, resulting in unmet care needs.
Failure to Provide Proper Oxygen Humidification and Tubing Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. Observations revealed that the resident, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was receiving oxygen via nasal cannula with an empty humidification bottle attached to the concentrator. The oxygen tubing in use was labeled with a date indicating it had not been changed in over three weeks. The resident reported experiencing a sore and dry nose, which coincided with the lack of humidification. Multiple observations confirmed the absence of humidification solution in the bottle over consecutive days. Interviews with staff, including an LPN and the DON, indicated that facility policy required weekly changes of oxygen tubing and regular monitoring and refilling of the humidification solution. The facility's own policies specified that humidification is required for oxygen flow rates of 4 liters and that the humidifier bottle should be changed when empty. Despite these policies, the resident's oxygen equipment was not maintained as required, resulting in discomfort and unmet care needs.
Medication Administration Error Rate Exceeds 5% Due to Improper Insulin Priming and Unobserved Medication Ingestion
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in a 7.69% error rate based on 2 errors in 26 observed opportunities. In one instance, a registered nurse (RN) was observed preparing an insulin pen for a resident but did not properly prime the pen according to manufacturer instructions. The RN primed the pen while holding it horizontally with the needle cover on and did not confirm that insulin was visible at the tip of the needle, nor did he repeat the priming process as required if insulin was not observed. Manufacturer instructions specify that the pen should be held with the needle pointing up, and insulin should be visible at the tip after priming, with steps to repeat if necessary. In another instance, the same RN left a prepared dose of Miralax on a resident's over-bed table and exited the room without confirming whether the resident was able to self-administer medications. The RN was unable to confirm the resident's ability to self-administer and stated he would return to observe the medication being taken. Facility policy requires that medications are administered at the time they are prepared and that staff observe residents to ensure the medication is completely ingested. These actions resulted in medication administration errors for two residents.
Failure to Inform Resident Representatives of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that resident representatives were properly informed about binding arbitration agreements and their right to refuse such agreements. For two residents, one with Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder, and another with non-Alzheimer's dementia, cerebrovascular accident, and seizure disorder, the responsible parties were not provided with an explanation of the arbitration agreement. In both cases, the residents signed the arbitration agreements before responsible parties were designated, and the agreements were not subsequently reviewed with those responsible parties. Interviews with the facility's social worker confirmed that the arbitration agreements were not discussed with the responsible parties after their designation. Review of the facility's policy indicated that the facility is required to explicitly inform residents or their representatives of their right not to sign the agreement, explain the agreement in an understandable manner, ensure acknowledgment of understanding, and grant the right to rescind within 30 days. These steps were not followed for the two residents in question.
Failure to Update Care Plan Interventions After Resident Falls
Penalty
Summary
The facility failed to update and revise care plan interventions for a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls and a history of cerebrovascular accident, muscle weakness, seizures, encephalopathy, impaired safety awareness, fatigue, use of antipsychotic medications, and prior falls, reported having fallen out of bed multiple times while attempting to reach for items or self-transfer. Despite these recent falls, the care plan interventions were not updated to reflect the resident's current status or to address additional preventative measures. The care plan had last been revised the day before the interview, but did not include new interventions based on the resident's recent fall history. During an interview, the DON acknowledged that the care plan interventions for falls should have been updated and revised to reflect the resident's current needs. The DON attributed the lack of timely care plan updates to recent staff changes, which made it difficult to ensure care plans were individualized and current. Review of facility policy and regulatory guidance confirmed that care plans must be reviewed and revised after each assessment and in response to changes in the resident's condition, goals, or needs.
Call Light System Malfunction in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light communication system was fully operational for six residents, leading to an inability to utilize the system for emergency care needs. This deficiency was observed through various interviews and record reviews, revealing that the call lights were not functioning for several residents, including Resident #2, who experienced a significant delay in receiving assistance for a bowel movement due to a non-operational call light. The Director of Nursing confirmed the malfunction and attempted a temporary fix by replacing the call light cord, but the issue persisted. Further observations and interviews with staff and residents indicated ongoing problems with the call light system, affecting multiple residents. Residents reported that call lights in bathrooms sometimes rendered the main room call lights inoperative, and staff acknowledged frequent issues with frayed cords and malfunctioning bulbs. The Nursing Home Administrator noted that despite audits and replacements, the call lights continued to fail without a discernible pattern, suggesting a systemic issue with the facility's call light system.
Failure to Provide Admission Information and Denture Loss
Penalty
Summary
The facility failed to provide a resident, identified as R2, with information regarding facility rules and regulations, including policies on denture loss, prior to or upon admission. R2 was admitted to the facility with upper and lower dentures, which were reported missing shortly after admission. The resident's family member, Complainant F, cleaned the dentures and placed them in a case on the bedside table. The following day, the dentures were missing, and the facility did not reimburse or replace them promptly. The Nursing Home Administrator (NHA) confirmed that the admission paperwork, including the acknowledgment of facility rules, was completed only after the dentures were lost. Interviews with facility staff, including CNA E, revealed that the dentures were last seen in a clear bowl on the bedside table. The facility's policy on lost or damaged personal property requires a prompt investigation, but there was no evidence that R2 or their representative received this policy before the dentures were lost. The facility's Dental Policy, which outlines the procedure for handling lost dentures, was also not provided to R2 upon admission. The NHA acknowledged the lack of documentation and could not provide additional information from the Admission Director regarding the delay in completing the admission paperwork. The facility's procedures for admission contracts and agreements require that all necessary documents be completed within 24 hours of admission. However, R2's admission documents were not completed until five days after admission, and two days after the dentures were lost. The facility's Resident Rights policy mandates that residents be informed of their rights and responsibilities both orally and in writing upon admission, but this was not done for R2. The NHA attempted to contact the Admission Director for further clarification but was unsuccessful before the survey concluded.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to respond timely to a change in condition for a resident, identified as R2, which resulted in a delayed transfer and treatment. On two consecutive days, a complainant noticed R2 in distress, with symptoms including flailing limbs and apparent pain. Despite these observations, the nursing staff initially dismissed the concerns as part of R2's decline. The following day, the complainant insisted on hospital transfer, but the attending RN delayed the process to complete a medication pass, resulting in a significant delay before R2 was sent to the hospital. R2's medical history included severe cognitive impairment and multiple active diagnoses such as cancer, heart failure, and urinary tract infection. The resident was unable to swallow and was lethargic, with symptoms worsening over several days. Despite these signs, there was a lack of timely intervention and communication with the physician, which contributed to the delay in addressing R2's deteriorating condition. The facility's documentation revealed inconsistencies in the assessment of R2's condition, further complicating the situation. The facility's policy for monitoring residents at risk was not effectively implemented, as R2 was not tracked by the interdisciplinary team prior to the transfer. The Director of Nursing acknowledged the delay in transferring R2 to the hospital and the failure to prioritize the resident's urgent needs over routine tasks. The Regional Clinical Director also confirmed that the facility lacked a specific policy for emergency transfers, which contributed to the inadequate response to R2's change in condition.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to appropriately assess and document the weights of residents, leading to significant weight loss in one resident and inadequate weight tracking for others. Resident R2, who was admitted with severe cognitive impairment and multiple health issues, experienced a significant weight loss of 30 pounds, as noted in a hospital progress note. The facility did not obtain an admission weight for R2, and only a few weight measurements were documented in the electronic medical record. The Nursing Home Administrator acknowledged the failure to obtain an admission weight for R2. Additionally, Resident R4 did not have an admission weight documented until three days after admission, and Resident R8 had missing weekly weight measurements for two weeks following admission. The Director of Nursing confirmed these lapses in weight monitoring and documentation. The facility's weight monitoring policy requires weights to be obtained upon admission, readmission, and weekly for the first four weeks, but this protocol was not followed for the residents in question.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement a comprehensive infection control program during a COVID-19 outbreak, resulting in significant adverse outcomes. The outbreak led to 40 out of 45 residents contracting COVID-19, with one death and multiple hospitalizations. The facility did not conduct adequate infection surveillance, tracking, or trending, and failed to implement effective transmission-based precautions. Observations revealed that staff did not consistently wear personal protective equipment (PPE) correctly, and there was a lack of proper signage and isolation measures for COVID-positive residents. The facility's Director of Nursing/Infection Preventionist admitted to not performing any monitoring or surveillance for infection control during the outbreak. The outbreak was exacerbated by a lack of testing and isolation of symptomatic individuals, including a certified nursing assistant who worked throughout the facility without being tested promptly. Residents continued to participate in group activities and dining, further contributing to the spread of the virus. The facility's policies on COVID-19 prevention and response were not effectively implemented, as evidenced by the lack of tracking and tracing of the outbreak. Additionally, the facility failed to implement a water management program and did not properly transport and sort linens to prevent cross-contamination. The Maintenance Director did not maintain records for water management, and laundry staff did not follow proper procedures for handling soiled linens. These deficiencies in infection control practices contributed to the sustained transmission of COVID-19 within the facility.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as observed during a survey. The hallways were noted to have stained and bleached carpets with separated seams, and multiple rooms had significant maintenance issues. For instance, a resident's room had a large gap between the bed mattress and footboard, posing an entrapment risk, and the radiator covers were missing, exposing metal fins that could cause injury. Another room had a strong urine odor, with a split seam in the vinyl flooring that allowed liquids to seep through, and the resident was noted to wear the same clothing for multiple days. Additional observations included a dining room with a patio door that had condensation and spider webs, broken cabinets, and stained carpets. Maintenance staff acknowledged these issues, noting that the gap between the mattress and footboard exceeded safe limits, and radiator covers were missing. Other rooms had broken furniture, chipped paint, and dirty mechanical lifts. The facility's closet doors were rusted and chipped, and air filters were covered in dust and debris. A leaking faucet and a rusty commode were also noted, along with a previous incident of a leaky ceiling in a resident's room. Interviews with staff revealed awareness of the facility's disrepair, with maintenance staff having previously obtained quotes for carpet replacement that were not acted upon. The Nursing Home Administrator acknowledged the concerns about the facility's environment, noting that the Maintenance Director was no longer employed due to not fulfilling job responsibilities. The report highlights the facility's failure to maintain a safe and homelike environment, as evidenced by the numerous maintenance and cleanliness issues observed during the survey.
Failure to Ensure Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs) had completed their yearly competency training, which includes demonstrating skills and techniques necessary for resident care. During interviews, the Director of Nursing (DON) admitted that competency training is supposed to be completed upon hire and annually but could not recall when the last competencies were completed. The DON referred the surveyor to the Human Resources/Business Office Manager, who also confirmed the absence of staff competencies. Further interviews revealed that the competencies were typically completed in May or June, but the records could not be located. Additionally, the Nursing Home Administrator (NHA) stated that there was no policy on competency training. The Facility Assessment, last updated in May, indicated that all nursing staff should complete a competency checklist annually.
Lack of Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct performance reviews for five Certified Nurse Aides (CNAs) within the required 12-month period. Personnel records revealed that CNAs hired as far back as 2016 and as recently as 2023 had not received any performance evaluations. During interviews, the Human Resource/Business Office Manager admitted to not having the staff evaluations and was unable to provide them upon request. Furthermore, the Nursing Home Administrator confirmed that the facility did not have a policy in place for conducting performance reviews for staff.
Failure to Post Resident Census on Staffing Sheets
Penalty
Summary
The facility failed to include the resident census information on the Nursing Department Daily Staffing sheets, which are used to calculate appropriate staffing levels. This omission was identified during a review of the direct care staffing hours on August 7, 2024, which revealed missing census information on multiple dates from January to March 2024. During an interview on the same day, the Nursing Home Administrator acknowledged the absence of the resident census on the staffing sheets and admitted that the sheets were not filled out correctly. The facility's policy on Nurse Staffing Posting Information, last revised in March 2024, mandates that the nurse staffing information should include the facility's current resident census.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and serving. During an initial tour of the kitchen, it was observed that expired food items, such as a gallon container of fruit salad and a container of soup, were not discarded. Additionally, several items in the walk-in refrigerator, including a jug of cranberry juice and apple juice, were found unlabeled and undated, contrary to the facility's expectations for marking perishable items with a use-by date. The facility also failed to maintain its freezers and ice machine in a sanitary condition. Three smaller freezers, used in place of a non-operational walk-in freezer, lacked thermometers to monitor temperatures, and one freezer had significant ice buildup, indicating improper maintenance. A package of frozen roast beef was found thawed and refrozen, suggesting temperature control issues. The ice machine was observed with a mold-like substance on its deflector shield, and there was no record of cleaning since it was procured from another facility. The Director of Maintenance was unaware of the issue and improperly attempted to clean the machine without removing the ice, risking contamination. Furthermore, the facility's dishwasher failed to properly sanitize items, as evidenced by test strips registering zero sanitizer levels during multiple tests. The dish machine logs for the first four days of August were incomplete, lacking records of chemical sanitization or temperature checks. These deficiencies collectively posed a risk of foodborne illness to the 46 residents receiving meals at the facility.
Inadequate Facility Assessment and Training Program
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. During interviews, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed a lack of awareness regarding the required training components that should be included in the facility assessment. Specifically, the competency and training list did not cover essential areas such as ethics, communication, resident rights, infection control, abuse and neglect, or Quality Assurance Performance Improvement (QAPI). The facility's policy on Facility Assessment, last revised in July 2023, mandates that the assessment should address facility resources, including personnel education and training related to resident care. However, a review of the Facility Assessment showed no evaluation of the training program to ensure that training needs were met for all staff and volunteers according to their roles. This oversight resulted in the potential for unidentified resources necessary to provide adequate care and services to the resident population.
Failure to Accurately Report Staffing Levels
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024, which revealed excessively low weekend staffing on multiple dates throughout January, February, and March. During an interview, the Nursing Home Administrator (NHA) admitted to not knowing what happened with the PBJ information, suggesting it might not have been entered correctly. The facility's policy, last revised in June 2024, mandates the electronic submission of complete and accurate direct care staffing information to CMS no less frequently than quarterly, with the NHA responsible for reviewing validation reports and ensuring corrections are made before the deadline.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement, monitor, and document an antibiotic stewardship program, which is a critical component of their infection prevention and control program. During interviews, the Director of Nursing/Infection Preventionist (DON/IP) admitted to not having a current listing for antibiotic stewardship for June or July and not tracing or monitoring the use of antibiotics. The DON/IP also stated that there was no written documentation for antibiotics on a line listing and that they relied solely on reports from the pharmacy without further tracking or monitoring. Further review revealed that the facility did not maintain any records of residents who received antibiotics, including details such as dosage, testing, or duration of antibiotic use. The monthly infection summary from July 2024 lacked any summary reports of infection data or antibiotic stewardship, including resistance patterns. There was no comparison of antibiotics to resident infections, nor documentation of whether the antibiotics were appropriate or effective. Additionally, there was no report of these findings to the Quality Assurance Performance Improvement (QAPI) meeting, as required by the facility's policies.
Failure to Educate and Offer COVID-19 Vaccinations to Staff
Penalty
Summary
The facility failed to educate and offer COVID-19 vaccinations to its staff, which increased the risk of COVID-19 infections and potential spread within the facility. During an interview, the Director of Nursing (DON) admitted that there had been no education about COVID-19 for staff, nor had the COVID-19 vaccine been offered to them. The Nursing Home Administrator (NHA) confirmed that while education and vaccination offerings were previously conducted, they had not been offered consistently or monthly. A Registered Nurse (RN) stated that in the nearly two years of working at the facility, they had not received education about COVID-19 or been offered the vaccine. The facility's policy on Employee Vaccinations, last revised in October 2023, stated that COVID-19 vaccinations would be provided to all healthcare providers per CDC guidelines. Additionally, the policy on COVID-19 Vaccination, last revised in March 2024, required the facility to educate and offer the vaccine to staff and maintain documentation of such actions. However, these policies were not followed, leading to the deficiency.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety risks for all 47 residents. During an observation of a resident's room, a significant gap was found between the mattress and the footboard, which was outside the acceptable measurement to prevent entrapment. This gap was confirmed by staff, who acknowledged it exceeded the safety standard of four inches. Interviews with staff revealed a lack of documentation for bed measurements, indicating that regular inspections were not being conducted. Maintenance staff admitted to not having any records of bed rail and mattress measurements, and the facility's Director of Nursing and other staff confirmed they had never witnessed such measurements being performed. The absence of documentation suggested that the required safety checks had not been completed since the previous maintenance director left the facility. The facility's policy, implemented in 2021, mandates regular inspections and maintenance of bed equipment to prevent entrapment. However, the lack of adherence to this policy was evident, as no records of inspections or maintenance were found. The facility's failure to ensure compatibility and safety of bed equipment posed a risk of injury to residents, highlighting a significant oversight in their maintenance program.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential zones of entrapment for all 45 residents. During an observation of a resident's room, a large gap was found between the bed mattress and footboard, which was confirmed to be outside the acceptable measurement to prevent entrapment. This gap was measured by staff and acknowledged as a safety risk. Interviews with maintenance staff and nursing staff revealed a lack of documentation for bed measurements and inspections. Maintenance Staff Q admitted that he could not find any records of bed measurements, and it was confirmed that such documentation had not been maintained since the previous Maintenance Director left the facility. The Director of Nursing and other staff members also confirmed that they had not witnessed any bed safety measurements being conducted. The facility's policy, implemented in 2021, requires regular inspections and documentation of bed equipment to prevent entrapment. However, the lack of adherence to this policy was evident, as no records were found, and staff confirmed that inspections had not been performed. This oversight posed a risk to residents, as the compatibility and safety of bed equipment were not ensured.
Inadequate Dietary Practices and Nutritional Deficiency
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form as prescribed by a physician. During a lunch meal service, the dietary tray line served a turkey casserole with diced turkey meat, which was not suitable for a resident who required a minced and moist diet due to conditions such as Alzheimer's disease, dysphagia, and malnutrition. The dietary manager admitted to not grinding the turkey and attempted to avoid giving the resident any chunks, despite the resident's care plan and physician's orders specifying a minced and moist texture. The facility's diet manual was outdated and did not include the current IDDSI diet level 5, which was necessary for the resident's dietary needs. Additionally, the facility failed to provide the appropriate nutritive content to 46 residents receiving meals from the dietary department. The turkey casserole recipe was intended to serve 50 residents with a portion size of 6 ounces, but only a 4-ounce scoop was used, resulting in approximately 1.5 ounces of protein per resident. This was below the standard meal plan pattern, which called for 3 ounces of protein with lunch. The consulting registered dietitian confirmed that the meal served did not meet the physician's order and that the facility's diet manual needed updating to reflect the current dietary standards.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written transfer notification to a resident and their representative, which is a requirement for transfers out of the facility. This deficiency was identified during a review of the case of a resident who was transferred to the hospital due to nausea, vomiting, and uncontrolled pain. During interviews, the Regional Clinical Consultant Registered Nurse admitted that the facility did not send written notifications and was unaware of this requirement. Additionally, the Nursing Home Administrator confirmed that although a transfer form was completed, it was not given or mailed to the resident or their representative.
Failure to Adhere to Wound Care Protocols and Infection Control Practices
Penalty
Summary
The facility failed to provide wound care according to the comprehensive care plan and physician orders for a resident, identified as R47, who was admitted following a short-term hospital stay. R47 had a history of stroke, aphasia, and hemiplegia, requiring supervision or assistance for certain movements. The physician's orders included specific instructions for wound care on the right buttock, which were not followed. During an observation, a registered nurse (RN) did not adhere to proper infection control practices, such as wearing eye protection and maintaining glove hygiene, while performing wound care. The RN used the same gloves after they became contaminated and failed to apply the correct dressing as per the physician's orders. Additionally, the RN did not perform hand hygiene after removing gloves and before donning new ones, which is a critical step in preventing infection. The RN also failed to ensure that the dressing was applied correctly and did not update the physician about the wound's condition in a timely manner. The resident's wound was found without a dressing, and barrier cream was improperly applied, indicating a lack of adherence to the care plan. Furthermore, a certified nurse aide (CNA) was instructed by the RN to apply a wound dressing, which is outside the scope of a CNA's practice. The CNA complied with the RN's request, despite understanding it was not within her duties. The facility's policy clearly states that wound care should be performed by licensed nurses, and the Director of Nursing confirmed that CNAs should not be applying wound dressings. This practice was previously identified and addressed by the DON, but it persisted, leading to the deficiency noted in the report.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident, identified as R50, who suffered a right hip fracture after an unwitnessed fall. R50 had severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, and was diagnosed with macular degeneration, falls, and acute respiratory failure with hypoxia. Despite these conditions, the facility did not implement a toileting program or frequent checks to address R50's needs, particularly after the room door was closed due to COVID-19 isolation of R50's roommate. R50's care plan included interventions for severe cognitive impairment, impaired visual function, and increased risk for falls. However, the care plan did not mention R50's legal blindness, which was a significant factor given her inability to see in the dark and reliance on peripheral vision. The facility's Fall Reduction Policy required a standardized risk assessment and interventions based on identified risks, but these were not effectively implemented for R50, who was unfamiliar with the facility's surroundings and had severe cognitive and visual impairments. Interviews revealed that two CNAs were on break, leaving limited staff available to assist R50, who was in a COVID-19 isolation room with a closed door. R50's roommate had to use a phone to call for help after R50 fell, as the call light might not have prompted immediate assistance. The Nursing Home Administrator acknowledged that frequent checks and a toileting program were not added to R50's care plan, despite her recent admission and significant impairments, which could have potentially prevented the fall.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to ensure that all staff members received training on resident rights, which is a critical component of their responsibilities in caring for residents. During a review of the computer training logs from a vendor, it was discovered that two Certified Nurse Aides (CNAs), hired in late 2022, had not completed the required resident rights training. This oversight was identified during an interview and record review conducted on August 7, 2024. Additionally, the Facility Assessment did not include a requirement for resident rights training, despite the facility's policy stating that all direct and indirect care staff must be educated on the rights of residents. This deficiency had the potential to impact the rights of all 45 residents in the facility.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received training on the Quality Assurance and Performance Improvement (QAPI) program. Specifically, a Certified Nurse Aide (CNA) who was hired on November 21, 2022, did not receive the required QAPI training. This was identified during a review of the computer training logs on August 7, 2024. Additionally, the facility's assessment did not include a requirement for QAPI training for staff, and the facility was unable to provide a QAPI policy before the surveyor's exit on August 12, 2024. This deficiency had the potential to result in unmet care needs due to an ineffective performance improvement program.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for one of the five staff members reviewed. Specifically, a Certified Nurse Aide (CNA) hired on March 14, 2023, did not receive the required infection control training. This oversight was identified during a review of the vendor's computer training logs. Additionally, the facility's assessment did not include a requirement for infection control training for staff, despite the facility's policy stating that all staff should receive training on the infection prevention and control program. This deficiency had the potential to contribute to the spread of diseases and infectious processes among all 45 residents in the facility.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as L and N, received the required minimum of 12 hours of annual in-service training. CNA L, hired on November 21, 2022, completed only 10 hours, while CNA N, hired on October 26, 2022, completed 11.75 hours. This deficiency was identified during a review of their training logs. The Human Resource/Business Office Manager indicated that the 12-hour training requirement is based on the CNA's hire date. The Nursing Home Administrator acknowledged the lack of communication to staff regarding training completion requirements, stating that the facility relies on a vendor-provided online training system, which was last revised in 2017, to manage CNA training. This oversight resulted in the potential for unmet care needs for all 45 residents in the facility.
Failure to Provide Safe and Orderly Involuntary Discharge
Penalty
Summary
The facility failed to provide and document a safe and orderly involuntary discharge for a resident, resulting in harm. The resident was discharged to his home without notifying family members living in the home, without provision of home health services, and without necessary medical equipment and supplies. This led to emotional distress and a return to the hospital due to unaddressed care needs. The resident had multiple medical conditions, including stroke, heart failure, end-stage renal disease, and dependence on a wheelchair, and required maximal assistance for daily activities. The discharge instructions indicated that the resident would require daily assistance for activities of daily living and that a home health agency would admit him the day after discharge. However, no services were in place at the time of discharge, and the home health agency assessment the following day resulted in a denial of services. The facility also failed to provide necessary medical equipment, such as oxygen supplies and catheter supplies, and did not complete a home assessment prior to discharge. The resident's Durable Power of Attorney (DPOA) was not present at the time of discharge, and the facility did not document a review of medications with the DPOA. Interviews with facility staff and the resident's DPOA revealed that the discharge was forced due to the resident's behavioral issues, but there was no consistent documentation of these behaviors. The facility did not provide a 30-day notice for the discharge, and the resident's family was not given a choice in the discharge decision. The resident's return home without adequate support and services led to significant distress for both the resident and his family, and the resident had to return to the emergency room for a urinary tract infection shortly after discharge.
Failure to Provide 30-Day Written Notice of Discharge
Penalty
Summary
The facility failed to provide a 30-day written notice of discharge to a resident, their representative, the Ombudsman, and the State Agency. The resident, who had multiple medical conditions including stroke, heart failure, and dementia, was discharged due to behavioral issues without proper notification and appeal rights. The discharge documentation indicated that the resident required daily assistance for activities of daily living and was dependent on a wheelchair for mobility. Despite these needs, the resident was sent home without a prior home safety assessment or adequate support in place. Interviews with facility staff revealed that the Social Services Director was aware of the resident's behavioral issues but did not follow the proper procedure for an involuntary discharge. The staff member admitted to not knowing the exact steps for such a discharge and confirmed that no 30-day notice was provided. The Ombudsman also confirmed that they had not received any notification of the resident's discharge, and the resident's representative stated that they were not given a choice in the discharge decision. The Nursing Home Administrator acknowledged that the discharge documentation clearly stated the resident was being discharged due to behavioral issues, yet the required 30-day notice was not provided. The resident and their family were left without the necessary support and were stressed by the sudden discharge. The facility's policy on transfers and discharges was not followed, resulting in a deficiency in providing proper notification and appeal rights to the resident and their representatives.
Inappropriate Involuntary Discharge and Lack of Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services pertaining to the discharge of a resident, resulting in an inappropriate involuntary discharge. The resident, who had multiple complex medical conditions including stroke, heart failure, end-stage renal disease, and dependence on a wheelchair, was discharged without proper planning and support. The discharge plan did not ensure that necessary home health services and medical equipment were in place, and the resident's wife was not informed about the discharge. Additionally, the resident's activated Durable Power of Attorney (DPOA) was not present at the time of discharge, and there was no documentation that the DPOA was informed about the medications or the discharge plan. The Social Services Director admitted that no 30-day notice of involuntary discharge was provided to the resident, the DPOA, the Ombudsman, or the State Agency. The resident was discharged home without a proper assessment of the level of care needed, and no home health care services were in place at the time of discharge. The Social Services Director also acknowledged that no supplies for the resident's suprapubic catheter were provided, and the resident had to borrow an oxygen concentrator from the facility without additional necessary supplies. The Social Services Director failed to document consistent behavior tracking for the resident, who was allegedly involved in an incident of inappropriate touching. Despite this, there was no evidence to show that the resident was a consistent and imminent threat to other residents. The discharge was carried out without proper communication and coordination with the resident's family and home health care agencies, leading to emotional distress and potential harm to the resident due to the lack of necessary care and support at home.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report timely an allegation of misappropriation of resident property (narcotics) to the State Agency (SA) for one resident. The resident, identified as R4, was admitted with diagnoses including neurocognitive disorder with Lewy Bodies, reduced mobility, and muscle weakness. The review of R4's medical records revealed inconsistencies in her cognitive assessments, with a significant change from being unable to complete the Brief Interview for Mental Status (BIMS) to scoring a 15/15 on a later assessment. The facility received a complaint about R4's Roxanol (Morphine Sulfate) being tampered with, but the Director of Nursing (DON) stated that it was not reported to the SA because the facility's internal investigation did not substantiate the claim. The investigation file was incomplete, with undated and unsigned witness statements and insufficient documentation to support the findings. Additional witness statements were only provided after the surveyor's request, and there was no statement from the pharmacists involved. The facility's policy mandates immediate reporting of such allegations, but this was not adhered to in this case. The facility's policy on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property requires that all allegations be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not. Despite this, the facility did not report the allegation of tampering with R4's medication to the SA within the required timeframe. The facility's failure to follow its own policy and federal and state laws regarding timely reporting of such allegations constitutes a deficiency in ensuring the protection of residents' health, welfare, and rights.
Incomplete Investigation of Alleged Medication Tampering
Penalty
Summary
The facility failed to conduct a thorough investigation for a misappropriation of resident property, specifically narcotic medication, for one resident. The resident, who had diagnoses including neurocognitive disorder with Lewy Bodies, reduced mobility, and muscle weakness, was admitted to the facility and had a prescription for Morphine Sulfate for end-of-life care. Despite the medication being refilled and delivered, the resident had not used any of it during the review period. The facility received a complaint alleging that the medication was tampered with, but the investigation was incomplete and lacked proper documentation and witness statements at the time of the initial report. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not report the incident to the State Agency because they believed the medication was not tampered with or missing based on their findings. However, the investigation file was insufficient, containing only one unsigned and undated witness statement, and pictures with no clear indication of what should be reviewed. Additional witness statements were only provided after the surveyor's request, and there was no statement from the pharmacist. The DON admitted that the investigation was not complete and that the medication was destroyed without proper documentation from the regional consultation and pharmacy.
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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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