Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Holly, Michigan.
- Location
- 313 Sherwood Street, Holly, Michigan 48442
- CMS Provider Number
- 235722
- Inspections on file
- 30
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with complex psychiatric and neurological diagnoses was subjected to mistreatment when a CNA placed a hand over the resident's mouth to muffle yelling during care. Another CNA witnessed the incident and reported it to facility management. The staff member involved expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health.
A resident admitted with alcohol dependence and withdrawal did not have the hospital's CIWA-Ar protocol for lorazepam administration reconciled or implemented upon admission. The DON and physician were unaware of the protocol on the discharge medication list, resulting in the protocol not being reviewed or acted upon.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Facility staff did not follow a psych NP's recommendation to rule out a UTI in a resident with dementia who exhibited behavioral changes. Despite a documented history of agitation linked to UTIs and ongoing symptoms, staff did not obtain a repeat urinalysis. The resident was later hospitalized, where sepsis and a UTI were diagnosed, and the DON acknowledged the recommendation had been missed.
A resident with dementia who required full staff assistance experienced a significant weight loss over a short period, but staff failed to confirm the loss, notify the DON, or update the nutrition care plan as required by facility policy. The DON was not informed of the weight change, and no follow-up actions were documented.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in the lack of a systematic process for identifying and addressing quality issues.
A resident with severe cognitive impairment and multiple diagnoses received opioid pain medications, but there were repeated discrepancies between the MAR and controlled substance records. Doses were documented as administered on the MAR but not reflected on the CS forms, with no refusals or explanations noted. The DON acknowledged gaps in the auditing process, and facility policy requiring reconciliation of controlled substance records was not consistently followed.
The facility's kitchen was found to have several sanitation deficiencies, including improper storage of raw and cooked foods, a dirty ice scoop holder, and a hose sprayer touching a soiled drain board. These issues were confirmed by the Dietary Manager and violated FDA Food Code regulations.
The facility failed to maintain a safe and clean environment, with deficiencies including overbed tray tables with exposed particle board, sharp sink vanity edges, soiled privacy curtains, and dusty ceiling vents. The Maintenance Manager acknowledged the issues but cited limitations in replacing tables, while the Maintenance & Housekeeping Manager did not provide clear responses regarding routine cleaning of vents.
A facility failed to ensure consistent documentation and communication for a resident receiving dialysis. The resident, with acute kidney failure and end-stage kidney disease, was scheduled for dialysis twice a week, but the MDS assessment did not reflect this. Documentation and assessments were missing for six treatments, and there was no follow-up with the dialysis center when paperwork was not returned. The DON confirmed the missing documentation and acknowledged the issue.
The facility failed to secure medication storage areas, with an LPN leaving a medication room door propped open and loose pills found in a medication cart. Insulin pens were improperly stored with food items, and a treatment cart was left unlocked near residents. The DON acknowledged these practices violated facility policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident with end-stage renal disease was incorrectly marked as not receiving dialysis, despite having orders for it. Another resident was inaccurately documented as being discharged to a hospital instead of an assisted living facility. The errors were acknowledged by the MDS Coordinator.
A resident with impaired cognition and multiple diagnoses was found with undated and dated dressings on their arm, with no orders for wound care documented. The facility failed to ensure proper assessments and documentation, as the Wound Care Nurse and Consultant Wound Provider were unaware of the dressings, and the LPN who applied the initial dressing did not recall placing an order for changes. The DON confirmed that nurses should ensure physician orders are in place, as per facility policy.
The facility failed to ensure proper infection control practices during medication administration for two residents. An LPN was observed not performing hand hygiene before and after administering oral medications and eye drops to a resident. Additionally, the LPN did not perform hand hygiene after retrieving and administering Gabapentin to another resident. The DON acknowledged the oversight, which was against the facility's hand hygiene policy.
The facility failed to ensure proper sanitizing and washing practices for dishes and utensils, and lacked proper hand washing facilities in the kitchen. The kitchen had been without hot water for weeks to months, leading staff to use boiling water for washing. However, the sanitizing process was not conducted according to standards, with expired test strips and incorrect solution temperatures. The facility's policy and FDA guidelines were not followed, posing a risk of improper sanitation.
A resident admitted for hospice respite care, with severe cognitive impairment and total dependence on staff for ADLs, did not have their clothing changed for two days. The facility's failure to update the care plan in a timely manner resulted in CNAs not being informed of the need to change the resident's clothing daily, as confirmed by the DON.
A facility failed to readmit a resident after a hospital transfer, despite the resident being medically cleared. The resident had severe cognitive impairment and a history of aggressive behavior, which was known prior to admission. The decision not to readmit was made by Corporate, but the facility did not provide the required documentation or notice to the family. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not followed.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Staff Mistreatment
Penalty
Summary
A staff member failed to protect a resident's right to be free from mistreatment. During an incident, a Certified Nurse's Aide (CNA) was observed placing her hand over a resident's mouth while the resident was yelling during care. Another CNA witnessed this action, which resulted in the resident's voice being muffled, and confronted the staff member. The CNA who committed the act reportedly expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health status. The incident was reported to the nurse manager and subsequently to the facility administrator. The resident involved had a medical history including parkinsonism, bipolar disorder with severe psychotic features, and schizoaffective disorder. The facility's policy prohibits abuse, neglect, and exploitation, and requires immediate investigation of any allegations. The staff member accused of the mistreatment was suspended and later terminated following the incident. The deficiency centers on the failure to protect the resident from physical and psychosocial harm by a staff member during the provision of care.
Failure to Reconcile and Implement CIWA-Ar Protocol on Admission
Penalty
Summary
The facility failed to ensure that all admission orders were reported and reconciled with the physician for a resident admitted with a primary diagnosis of alcohol dependence with withdrawal. Upon review, it was found that the hospital discharge medication list included a CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) protocol for administering lorazepam based on withdrawal assessment scores. This protocol specified dosing and reassessment intervals, as well as instructions to notify the provider if certain thresholds were met. However, the as-needed CIWA protocol was not reconciled or implemented upon admission, unlike the other medications listed on the discharge summary. Interviews with the Director of Nursing (DON) and the assigned physician revealed that neither was aware of the CIWA protocol included in the hospital discharge documentation. The physician confirmed that they had not been informed of the protocol, and the DON acknowledged being unaware of its presence on the discharge medication list. There was no documentation or evidence that the protocol was reviewed or acted upon at the time of admission.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Follow Psych NP Recommendation and Identify UTI in Resident with Behavioral Changes
Penalty
Summary
Facility staff failed to follow the recommendation of a psychiatric nurse practitioner to rule out underlying medical causes, specifically a urinary tract infection (UTI), in a resident with dementia who exhibited increased anxiety, agitation, and aggression. The psych NP had documented that the resident had a history of significant agitation in the presence of acute medical issues, particularly UTIs, and advised that if behavioral changes persisted, a repeat urinalysis should be considered. Despite ongoing behavioral changes, the medical record showed that a repeat urinalysis was neither considered nor obtained as recommended. The resident continued to display behavioral disturbances, including verbal aggression toward another resident, and was later transported to the hospital by family due to concerns about a change in mental status. Hospital records confirmed the presence of sepsis due to Enterobacter species, with bacteremia secondary to a UTI, and the resident was started on intravenous antibiotics. The Director of Nursing later acknowledged being unaware of the psych NP's recommendation and confirmed that the repeat urinalysis had been missed.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, follow up, and adhere to its policy regarding significant weight loss for one resident with dementia who required staff assistance for all activities of daily living. The resident experienced a weight loss of 16.4 pounds in less than a month, as documented in the medical record. There was no evidence that a re-weight was performed to confirm the loss, nor was there any documentation of clarification of the recorded weight, notification to the dietician or physician, monitoring, or interventions or modifications to the resident's nutrition plan of care. The facility's policy required comparison of newly recorded weights to previous weights to determine if a re-weight was necessary, but this process was not followed. The DON confirmed that they were not notified of the weight loss and that therapy staff, who obtained the weights, did not inform them of the significant change.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for one resident, as evidenced by multiple discrepancies between the Medication Administration Records (MARs) and the corresponding Controlled Substance (CS) records. The resident in question had diagnoses including fibromyalgia, cerebral atherosclerosis, and unspecified dementia with agitation, and was receiving both scheduled and PRN opioid pain medications. The MARs indicated that medications such as Hydrocodone-Acetaminophen and Morphine Sulfate were administered at scheduled times, but these administrations were not consistently documented on the CS forms as required. Specific instances were identified where the MAR showed that doses were given, but there was no corresponding entry on the CS form, nor any documentation of refusal or explanation in the progress notes. For example, doses of Hydrocodone-Acetaminophen and Morphine Sulfate were marked as administered on the MAR but were missing from the CS records on several dates. In some cases, the CS forms reflected different administration times or omitted doses entirely, and in other cases, doses were documented as held on the MAR but still recorded as removed on the CS form. During an interview, the Director of Nursing acknowledged awareness of issues with controlled substance documentation and described a process of auditing CS forms for missing entries, but not for discrepancies between the MAR and CS forms. Facility policy required that controlled substance inventory be regularly reconciled with the MAR and documented accordingly, but this was not consistently followed, resulting in incomplete and inaccurate records for controlled substance administration.
Sanitation Deficiencies in Kitchen Storage and Equipment
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. In the Traulsen reach-in cooler, raw chicken was stored directly on top of a box of cooked diced chicken, and raw pork was placed on top of a box of corn chowder soup. This improper storage of food items was confirmed by the Dietary Manager (DM) J, and it violated the 2017 FDA Food Code section 3-302.11, which mandates the separation and segregation of raw animal foods to prevent cross-contamination. Additionally, the ice scoop holder was found with black debris on the inside bottom surface, which was acknowledged by DM J. This condition did not comply with the FDA 2017 Model Food Code, Section 3-304.12, which requires in-use utensils to be stored in a clean, protected location. Furthermore, the hose sprayer at the soiled side of the dish machine was observed hanging down and touching the soiled drain board, which was also noted by DM J. This situation contravened the 2017 FDA Food Code section 5-202.13, which requires an air gap to prevent backflow contamination.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Overbed tray tables in multiple rooms, including D150, D151, D156, and others, were found with missing plastic edging and exposed rough particle board, making them difficult to sanitize properly. Additionally, the sink vanities in rooms C138, C142, and C143 had sharp edges due to missing laminate, posing a potential safety hazard. The privacy curtain in room D151 was soiled with dark brown debris, and the ceiling vent covers in the main dining room and fishbowl lounge were coated with dust, with mold-like stains observed on the ceiling surrounding one of the vents. The Maintenance Manager acknowledged awareness of the issues with the overbed tray tables but stated that the facility could only replace two tables per month. Despite being fully staffed, the Maintenance & Housekeeping Manager did not provide a clear response regarding the routine cleaning and maintenance of vents, relying instead on a contracted company to clean them three times a year. The electronic reporting system used for maintenance issues was mentioned, but no concerns with privacy curtains were acknowledged. The inability to properly sanitize the porous surfaces of the tray tables was recognized, yet the replacement rate remained limited to two tables per month.
Inadequate Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure consistent documentation and communication for a resident receiving dialysis services. The resident, who was admitted with acute kidney failure, end-stage kidney disease, and dependence on renal dialysis, was scheduled for dialysis every Tuesday and Saturday. However, the Minimum Data Set (MDS) assessment did not identify the resident as currently receiving dialysis services. Additionally, there were missing documentation and assessments for six dialysis treatments, indicating a lack of communication and assessment of the resident's condition pre and post dialysis. The facility's policy required nursing staff to provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis day. If no written report was received upon the resident's return, the nursing staff was to call the dialysis provider for a report. Despite this policy, there was no documentation of follow-up communication with the dialysis center when paperwork was not returned with the resident. The Director of Nursing confirmed the missing documentation and assessments, acknowledging the concern.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications and biologicals, as observed in two medication rooms, one treatment cart, and one medication cart. During a medication administration observation, an LPN propped open the medication room door with a crash cart, leaving it unattended and accessible. Loose pills without patient identifiers were found in a medication cart drawer, which were acknowledged by an LPN and disposed of improperly. Additionally, the medication storage room on D hall contained insulin pens stored improperly alongside food items, including a large opened container of applesauce and moldy grapes. The treatment cart on D hall was found unlocked and unsupervised, with three residents seated nearby. A nurse returned to the medication cart next to the treatment cart but did not secure the treatment cart until prompted by the surveyor. The facility's policy requires that medication rooms, carts, and supplies be locked when not attended by authorized personnel, and refrigerated medications be stored separately from food items. The Director of Nursing acknowledged the issues and confirmed that the observed practices were against facility policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the Minimum Data Set (MDS) evaluations. One resident, who was admitted with acute kidney failure and end-stage renal disease, was incorrectly marked as not receiving dialysis in their MDS assessment, despite having physician orders for dialysis twice a week since admission. The MDS Coordinator, Nurse 'E', acknowledged the error, stating they were unaware of the resident's dialysis treatment, which was documented in the resident's orders and progress notes. Another resident, admitted with dementia, atrial fibrillation, and hypertension, was inaccurately documented as being discharged to a short-term general hospital in their MDS assessment. However, records indicated the resident was actually discharged to an assisted living facility. Nurse 'E' admitted to mistakenly selecting the wrong discharge location during the assessment process.
Failure to Ensure Proper Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate assessments, monitoring, and treatments for a resident with non-pressure wound care needs. The resident, who had moderately impaired cognition and required assistance for all activities of daily living, was observed with undated and dated dressings on their left arm, with visible drainage. The clinical records did not contain any orders for wound care or dressing changes, and the resident was unsure of the reason for the bandages. A skin tear was noted after the resident rolled out of bed, but no further assessments or documentation were completed. The Wound Care Nurse and a Consultant Wound Provider were unaware of the dressings on the resident's arm, and the Licensed Practical Nurse who initially dressed the wound did not recall placing an order for dressing changes. The Director of Nursing confirmed that nurses should ensure physician orders are in place for dressings and treatments. The facility's policy requires wound treatments to be provided according to physician orders and documented appropriately, which was not followed in this case.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices during medication administration for two residents. On the morning of February 5th, a Licensed Practical Nurse (LPN) was observed administering oral medications to a resident without performing hand hygiene before or after the process. Additionally, the LPN retrieved and administered lubricating eye drops to the same resident without performing hand hygiene, even after donning gloves. The LPN later acknowledged the oversight in hand hygiene. Later that morning, the same LPN was observed administering Gabapentin to another resident without performing hand hygiene after retrieving the medication from a separate medication room. The Director of Nursing was informed of these incidents and acknowledged that hand hygiene should be performed before and after medication administration, as per the facility's hand hygiene policy dated January 2024.
Improper Sanitizing Practices and Lack of Hot Water in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitizing and washing practices were used to clean dishes and utensils, and did not provide proper hand washing facilities in the kitchen. This deficiency was identified during an investigation following a complaint about the lack of hot water in the kitchen. Observations revealed that the kitchen staff were using boiling water to wash dishes and utensils, and then rinsing and sanitizing them in a three-compartment sink. However, the sanitizing process was not conducted according to professional standards, as the sanitizing solution was not at the correct temperature and the test strips used to check the solution's concentration were expired. Interviews with staff members, including the Administrator and Dietary Manager, confirmed that the kitchen had been without hot water for weeks to months. The staff reported using disposable foam containers and plastic cutlery to serve food, while reusable items were washed with boiling water. Despite these efforts, the sanitizing process was not properly executed. For instance, a staff member was observed submerging a pot in the sanitizing solution for only one second instead of the required one minute, and another staff member did not test the sanitizing solution before use. The facility's policy on the use of the three-compartment sink was not followed, as the sanitizing solution was not tested for appropriate concentration before use, and the water temperature was not maintained at the required level. The FDA Food Code specifies that handwashing sinks must provide water at a minimum temperature, and the sanitizing solution must be at a specific temperature and concentration. These requirements were not met, leading to the potential risk of improper sanitation of dishware and utensils used by the residents.
Failure to Assist Resident with Dressing
Penalty
Summary
The facility failed to provide assistance with dressing for a resident who was admitted for hospice respite care. The resident, who had diagnoses including heart failure and dementia, was totally dependent on staff for activities of daily living, including dressing. A complaint was submitted alleging that the resident's clothing was not changed for two days. Upon investigation, it was confirmed that the resident's clothing was indeed not changed during this period. The Director of Nursing (DON) confirmed that the care plan for the resident was not updated in a timely manner to include tasks for changing the resident's clothing daily. The resident's family had provided clothing and a nightgown for each day of the stay, and it was the facility's expectation that clothing would be changed daily. However, due to the lack of an updated care plan, the Certified Nursing Assistants (CNAs) were not informed of this task, leading to the deficiency.
Failure to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to permit a resident, who was transferred to the hospital, to return to the facility after being medically cleared. The resident, who had severe cognitive impairment and a history of aggressive behavior, was initially admitted to the facility despite known behavioral issues. The facility's decision not to readmit the resident was made by Corporate, citing the resident's aggressive behavior and attempts to elope as reasons. However, the facility did not provide the required documentation or notice to the resident's family regarding the decision not to readmit. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not adhered to in this case. The Nursing Home Administrator and Director of Nursing acknowledged that the resident was not an appropriate admission, and the Admissions Director indicated that Corporate had instructed the facility to increase admissions, leading to the acceptance of the resident. The facility's failure to follow proper procedures and provide adequate notice resulted in a deficiency citation.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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