Munson Healthcare Crawford Continuing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grayling, Michigan.
- Location
- 1100 Michigan Avenue, Grayling, Michigan 49738
- CMS Provider Number
- 235201
- Inspections on file
- 16
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Munson Healthcare Crawford Continuing Care Center during CMS and state inspections, most recent first.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility failed to implement proper infection control measures, affecting multiple residents. A resident's urinary catheter bag was found on the floor, and another resident's drinking cup was placed on the floor and not sanitized before use. A resident with Influenza A lacked an infection care plan, and soiled linens were improperly handled. Additionally, a CNA did not sanitize hands between glove changes while feeding two residents. The DON confirmed these actions violated facility policies.
A resident was placed on end-of-life care without a physician's order or care plan, and the durable power of attorney was activated without proper assessments. The resident was admitted for therapy services and was alert and oriented, but the family decided on comfort care without documented physician assessments indicating the resident's incapacity to make medical decisions.
A facility failed to assess and document the use of a reclining wheelchair as a physical restraint for a resident with Alzheimer's and Parkinson's. The resident, unable to disengage the leg rest independently, was placed in the chair for safety without proper assessments or documentation. Interviews with staff revealed uncertainty about the restraint's classification, and the facility's policy on restraint-free environments was not followed, leading to potential negative outcomes.
The facility failed to ensure MRRs were reviewed and addressed by physicians for two residents, leading to potential medication management risks. One resident with severe cognitive impairment had no MRR documentation for several months, and recommendations for a digoxin level test were not addressed. Another resident's MRRs and physician responses were missing for two months, with incomplete blood test recommendations followed. The facility's policy on MRR documentation was not followed.
The facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medication to two residents with severe cognitive impairments. Despite care plans outlining strategies like redirection and therapeutic listening, these were not documented as attempted prior to medication use. Facility policies require non-pharmacological interventions to be tried and documented before using medications, but this was not adhered to, as revealed by record reviews and interviews with the DON.
The facility failed to maintain food safety standards during meal preparation and service. Fresh-cut cantaloupe melon was served at temperatures above the safe range, and the kitchen had discontinued using a cleaner for the melons' exterior. Additionally, mechanical chicken was served at temperatures below the required holding temperature. These deficiencies violate the 2017 FDA Food Code and pose a risk of foodborne illness to residents.
The facility failed to report PBJ information to CMS, leading to inaccurate staffing level reports potentially affecting all 26 residents. The CMS PBJ Staffing Data Report for FY Quarter 2 2024 showed a lack of 24-hour licensed nursing coverage and no RN hours, with daily infractions. The Business Office Manager, responsible for PBJ submissions, could not provide confirmation of successful submission for the required period.
The facility failed to implement an effective QAPI program, as the DON was unaware of Performance Improvement Projects and could not provide evidence of regular review or data analysis. The facility's policy outlines necessary QAPI elements, but documentation and evidence of an ongoing program were lacking, potentially affecting all 26 residents.
The facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings quarterly, as required by policy. The Director of Nursing (DON) confirmed the IP's absence from the last three meetings, which could lead to ineffective interdisciplinary communication affecting all 26 residents.
The facility failed to track communicable diseases during a Covid-19 outbreak, potentially exposing 23 residents. The DON did not maintain detailed records or conduct a required RCA. Additionally, the facility's laundry procedures for contaminated items were not followed, risking pathogen transmission. Laundry staff were unaware of proper disinfectant use, and chemicals were incorrectly connected.
The facility did not have a qualified Infection Preventionist working at least part-time, leading to inadequate management of the Infection Prevention and Control Program. The DON and an RN were in the process of completing necessary training but had not finished. The hospital affiliate Infection Preventionist was only a resource and did not provide oversight. The facility failed to conduct outbreak investigations or track symptoms for a Covid-19 outbreak, and no official records of illness were kept unless antibiotics were prescribed.
The facility failed to provide written notifications to residents or their representatives for transfers to acute care hospitals. Three residents were transferred due to medical conditions such as acute anemia, respiratory failure, and hypokalemia without receiving written notices. The Business Officer Manager confirmed the lack of written notifications and admitted to not being trained to complete transfer agreements.
The facility failed to provide safe wheelchair mobility assistance for three residents, as foot pedals were not used, posing injury risks. Additionally, the facility did not investigate a self-injurious incident involving a resident with dementia, as the DON was unaware of the event and no investigation was initiated. The lack of a policy on resident supervision and safety was also noted.
A facility failed to investigate allegations of abuse involving a resident with severe cognitive impairment, who was involved in two incidents with another resident. Despite the resident reporting a threat of harm, no investigations were conducted as there was no physical contact. This inaction violated the facility's policy, which requires thorough investigations of all abuse reports, including verbal threats.
A resident with dementia and impaired cognitive skills was found with a call light cord around her neck, yet her care plan lacked interventions for her impulsive behavior and safety needs. Staff confirmed the need for frequent safety checks, but these were not documented, leading to potential unmet safety needs.
A resident with chronic respiratory failure and hypoxia was not administered supplemental oxygen as per physician orders. The resident was observed multiple times without her prescribed oxygen, and staff interviews revealed a misunderstanding of her oxygen requirements. Despite an order for continuous oxygen, there was no documented physician directive to trial weaning off the oxygen, and the facility's policy lacked guidance on oxygen weaning.
A resident with acute pain due to trauma and contusions experienced untreated leg cramps and muscle spasms, despite repeated complaints documented in her EMR. The facility failed to follow its pain management policy, as no physician addressed her pain, and communication errors were identified by the Clinical Care Coordinator/RN.
A facility failed to conduct a gradual dose reduction (GDR) for a resident on olanzapine, despite recommendations from the Consultant Pharmacist. The resident, with dementia and delusional disorders, continued receiving the same dosage without documented evaluation or rationale for not performing the GDR. The Nursing Home Administrator cited issues with medical providers' understanding of GDR regulations.
A facility failed to maintain a medication administration error rate below five percent, resulting in a 6.45 percent error rate. Errors included a missed dose of gabapentin due to unavailability and incorrect documentation, and improper insulin administration using a Humalog KwikPen without priming. These errors affected a resident and were due to staff not following procedures and being unaware of medication administration requirements.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures, affecting five residents. Resident #5 was observed with a urinary catheter drainage bag and tubing dragging on the floor beneath her wheelchair on multiple occasions, without a barrier to prevent contamination. Resident #10 had a plastic drinking cup placed on the floor, which was later picked up by a registered nurse and placed on a table without sanitization or replacement. Resident #23, diagnosed with Influenza A, did not have an infection care plan to guide staff in preventing the spread of the virus. Additionally, a certified nurse aide was seen placing soiled linen bags on the floor instead of in the designated soiled utility room. Further observations revealed that a certified nurse aide was feeding two residents simultaneously while wearing examination gloves, changing gloves without sanitizing hands in between. A bag containing clean clothing protectors was also found on the floor in the dining room. The Director of Nursing confirmed that these practices were against the facility's policies, which require hand sanitization between glove changes, proper handling of soiled linens, and ensuring that urinary catheter bags and drinking cups are not placed on the floor. The facility's policies on infection control and urinary catheter care were not adhered to, contributing to the deficiencies observed.
Failure to Properly Activate DPOA and Establish EOLC Plan
Penalty
Summary
The facility failed to ensure that a resident, who was placed on end-of-life care (EOLC), had a care plan and physician's order for terminal care, and that the activation of the patient's advocate/durable power of attorney was appropriately conducted. The resident was admitted for skilled therapy services and was alert and oriented, as documented in the nurses' progress notes. However, a progress note indicated that the family decided to make the resident comfort care without a physician's order for EOLC or a care plan in place. Additionally, there were no documented assessments by physicians indicating that the resident was incapable of making medical treatment decisions, which was necessary to activate the patient advocate designation. The facility's social services director and the director of nursing confirmed that the durable power of attorney should not have been activated without assessments by two physicians declaring the resident incapable of making medical decisions. The facility's policy required that if a patient loses decision-making capacity, the DPOA must be activated by the attending physician and one other physician. In this case, the resident's daughter was allowed to make decisions regarding EOLC without the proper assessments and documentation, leading to a deficiency in the facility's handling of the resident's end-of-life care.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to provide appropriate assessments and documentation for the use of a physical restraint on a resident diagnosed with Alzheimer's dementia and Parkinson's Disease. The resident, who was unable to participate in the Brief Interview for Mental Status and was assessed to have severely impaired cognition, was observed multiple times seated in a reclining wheelchair with the leg rest engaged in the up position. The resident was unable to disengage the leg rest independently, and staff repositioned the resident without documented assessments or justification for the use of the reclining wheelchair as a restraint. Interviews with facility staff, including a CNA and the Director of Nursing (DON), revealed that the resident was placed in the reclining wheelchair for safety reasons, as the resident exhibited fidgety behavior and was at risk of falling forward when tired. However, the DON was unsure if the reclining wheelchair should be considered a restraint and confirmed that no assessments were completed to ensure the resident's safety or ability to remove themselves from the chair independently. The resident's care plan indicated the use of a geri chair for comfort and positioning but lacked documentation of behaviors or restlessness targeted by the use of the reclining wheelchair. The facility's policy on a restraint-free environment requires documentation of medical symptoms warranting the use of restraints, attempts of less restrictive alternatives, and ongoing re-evaluation of the restraint's necessity and effectiveness. The resident's electronic medical record lacked documentation of these requirements, and no regular assessments were conducted to ensure the resident's safety and psychosocial well-being while using the reclining wheelchair. This oversight resulted in the potential for negative outcomes such as decreased physical functioning and loss of autonomy and dignity.
Failure to Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRR) were properly reviewed and addressed by the physician for two residents, resulting in potential risks related to medication management. For Resident #3, who has severe cognitive impairment and diagnoses including heart failure and dementia, there was no documentation of MRRs in the electronic medical record from August 2024 to December 2024. Although a paper record indicated a review was conducted in December 2024, no pharmacy recommendations were documented. Further, recommendations made in January 2025 regarding the need for a digoxin level test were not addressed by the nursing staff or the physician, and the last recorded digoxin level test was from March 2024. For Resident #23, who is cognitively intact and has multiple diagnoses including atrial fibrillation and renal insufficiency, the medical record lacked MRR recommendations and physician responses for November and December 2024. The Director of Nursing (DON) was unable to provide documentation of the MRR for November 2024 and reported that only one of the recommended blood tests from December 2024 was obtained, with no documentation from the physician regarding the declination of additional tests. The facility's policy requires that MRRs and prescriber responses be documented and maintained, which was not adhered to in these cases.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure proper documentation and implementation of non-pharmacological interventions before administering as-needed (PRN) anti-anxiety medication to two residents. Resident #3, who was admitted with dementia and depression, had severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status (BIMS). The resident's Medication Administration Record (MAR) showed multiple instances where lorazepam was administered without documentation of specific behaviors or symptoms, and without evidence of attempted non-pharmacological interventions. The care plan for Resident #3 included interventions such as redirection with snacks or conversation, but these were not documented as attempted prior to medication administration. Resident #10, diagnosed with Alzheimer's dementia and Parkinson's Disease, also exhibited severely impaired cognition. The MAR for this resident indicated that lorazepam was administered for anxiety and agitation, but there was a lack of documentation regarding specific behaviors and non-pharmacological interventions prior to medication use. The care plan for Resident #10 included strategies like stopping and reapproaching if the resident was uncooperative, and providing therapeutic listening, but these were not documented as being attempted before administering lorazepam. The facility's policies on Behavioral Health Services and Behavior and Symptom Management require that non-pharmacological interventions be tried and documented before resorting to pharmacological measures. However, the review of the electronic medical records and interviews with the Director of Nursing revealed that these protocols were not followed, leading to the administration of PRN medications without proper documentation and attempts at non-pharmacological interventions.
Food Safety Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. During the morning meal service, a large pan of fresh-cut cantaloupe melon was found to have temperatures ranging between 45°F and 48°F, which is above the recommended safe temperature for cold foods. Dietary Aide E mentioned using a special wash for the melon, but Prep Cook F revealed that the kitchen had stopped using any cleaner for the exterior of the melons a year prior. The Certified Dietary Manager confirmed the absence of a process to ensure thorough cleaning of the melons, which is a violation of the 2017 FDA Food Code that requires raw fruits and vegetables to be thoroughly washed before being cut or served. Additionally, during the noon meal observation, a pan of mechanical chicken was found to have temperatures between 119°F and 131°F, which is below the required holding temperature of 135°F as per the FDA Food Code 2017. Dietary Aide E stated that the temperatures had been taken and the food was ready for service, indicating a failure to maintain the appropriate temperature for hot foods. This deficiency in maintaining proper food temperatures and cleaning procedures poses a risk of foodborne illness to the 26 residents in the facility.
Failure to Report PBJ Information to CMS
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 had the potential to affect all 26 residents in the facility. During the review of the CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024, it was found that the facility did not maintain licensed nursing coverage 24 hours a day and had no Registered Nurse (RN) hours, with daily infractions occurring from January 1 to March 31, 2024. An interview with the Business Office Manager (BOM) revealed that she was responsible for submitting the PBJ information but was unable to provide confirmation emails from CMS indicating successful submission of the required information for Quarter 2 of 2024. The PBJ XML Submission Process requires that after submission, a Final Validation Report is generated within 24 hours, detailing any errors found during the validation of the records in the PBJ submission file.
Facility's QAPI Program Lacks Implementation and Documentation
Penalty
Summary
The facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program, which is crucial for maintaining quality care standards. During an interview, the Director of Nursing (DON) admitted to being unaware of the concept of a Performance Improvement Project (PIP) and was unable to provide any formal records of such projects. The DON also could not present evidence of regular review or data analysis under the QAPI program, including tracking and measuring performance, establishing goals and thresholds for performance improvements, or monitoring and evaluating the effectiveness of corrective actions. The DON expressed difficulty in understanding the requirements of the QAPI program due to insufficient orientation for the role. The facility's policy on Quality Assurance and Performance Improvement, revised in July 2023, outlines the necessary elements of the QAPI plan, including tracking performance, setting goals, identifying deficiencies, analyzing causes, and implementing corrective actions. However, the facility failed to maintain documentation or demonstrate evidence of an ongoing QAPI program. This deficiency had the potential to affect all 26 residents in the facility, as the lack of a structured QAPI program could lead to unaddressed quality issues and systemic deficiencies.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis, as required. This deficiency was identified through an interview with the Director of Nursing (DON) and a review of attendance documents from the previous three quarterly meetings, which confirmed the absence of the IP. The DON acknowledged that the IP does not attend these meetings and instead serves as a resource in the acute-care portion of the facility. The facility's policy on Quality Assurance and Performance Improvement, revised on July 12, 2023, mandates that the Quality Assessment and Assurance (QAA) Committee be interdisciplinary and include the IP as a member. The absence of the IP from these meetings resulted in the potential for ineffective interdisciplinary communication regarding facility processes, potentially affecting all 26 residents residing in the facility.
Deficiencies in Infection Control and Laundry Procedures
Penalty
Summary
The facility failed to implement a system for recording and tracking communicable diseases during a Covid-19 outbreak, which potentially exposed 23 uninfected residents to the virus. The Director of Nursing (DON), who was also the acting Infection Preventionist, did not maintain a written summary of the outbreak or systematically track infections that did not require antibiotic use. Although the facility conducted testing on residents and staff, the DON could not provide detailed information on the symptoms, onset, or resolution of the illness for the Covid-19 positive residents. The facility's policy required a Root Cause Analysis (RCA) after an outbreak, but no RCA was conducted to evaluate the effectiveness of the actions taken or to identify areas for improvement. The facility also failed to develop and implement appropriate laundry policies and procedures for residents' personal laundry, which could prevent the transmission of resistant pathogens. The existing policy outlined procedures for handling potentially contaminated laundry, including the use of red bags and specific washing instructions. However, the DON acknowledged that the policy was not followed, as potentially contaminated laundry was sent to the hospital laundry staff, who used yellow bags instead of red and did not use bleach or high-temperature wash cycles as required. Interviews with the hospital laundry manager, laundry staff, and maintenance supervisor revealed that the chemicals used in the washing machine were not connected correctly, and there was no awareness of the need to use or monitor chlorine disinfectant levels. The facility's policy did not address the need to ensure proper disinfectant levels during the washing process, leading to a failure in preventing the transmission of infections through laundry handling.
Inadequate Infection Preventionist Presence and Program Management
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist was working at least part-time, which resulted in inadequate management of the Infection Prevention and Control Program. The Director of Nursing (DON) was responsible for infection prevention duties but had not completed the necessary Infection Preventionist training. Similarly, Registered Nurse (RN) L was also in the process of completing the training but had not finished. The hospital affiliate Infection Preventionist, RN Q, was only a resource and did not provide actual oversight or part-time presence at the facility. During a review of the facility's Infection Control Program, it was found that there was no outbreak investigation or symptom tracking for a Covid-19 outbreak in March 2024. The DON admitted to not systematically tracking infections that did not require antibiotic use, and no official records of illness onset or resolution were kept unless antibiotics were prescribed. The facility's policy did not include the regulatory requirement for a qualified Infection Preventionist to work on-site at least part-time.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfers to acute care hospitals. This deficiency was identified for three residents who were transferred due to various medical conditions. Resident #82 was transferred twice, first for acute anemia and then for acute blood loss anemia, without receiving a written notice. Similarly, Resident #186 was sent to a hospital for acute respiratory failure with hypoxemia, and Resident #27 was transferred due to leukocytosis and severe hypokalemia, both without written notifications. During the survey, it was confirmed through an interview with the Business Officer Manager (BOM) that the facility did not issue written notifications for transfers or discharges. The BOM admitted to not having completed a transfer agreement and not being trained to do so. Additionally, the facility did not provide a transfer policy by the time of the survey exit, further indicating a lack of compliance with the requirement to notify residents or their representatives in writing about transfers or discharges.
Deficiencies in Wheelchair Mobility Assistance and Incident Investigation
Penalty
Summary
The facility failed to provide safe assistance with wheelchair mobility for three residents, leading to potential injury risks. During observations, it was noted that two residents were assisted to the dining room in wheelchairs without foot pedals, causing their feet to scrape the ground or requiring them to hold their feet up. A staff member admitted that foot pedals were rarely used for residents who could self-propel, citing time constraints as the reason for not retrieving them from residents' rooms. This practice posed a risk of injury or falls, as residents might not understand the need to keep their feet off the floor. Additionally, the facility did not investigate the root cause of self-injurious behavior for a resident with dementia. The resident was found with a call light cord wrapped around her neck, an incident that was not reported or investigated by the facility. The Director of Nursing (DON) was unaware of the incident until informed by the surveyor and confirmed that no investigation had been initiated. The resident had a history of impulsive behavior and required frequent checks to ensure her safety, but the incident was treated as isolated without further inquiry. The facility's lack of a policy related to resident supervision and safety was highlighted, as no such policy was provided upon request. The failure to investigate the self-injurious behavior and the unsafe wheelchair mobility assistance practices indicate deficiencies in the facility's supervision and safety protocols, potentially compromising resident safety.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse policy and investigate allegations of abuse involving a resident with severe cognitive impairment, who was admitted with diagnoses including stroke, dementia, and right-side hemiparesis. The resident was involved in two separate incidents where they were found in potentially threatening situations with another resident. In the first incident, staff intervened when the resident was yelling in the dining room due to another resident being in close proximity, although no physical contact occurred. In the second incident, the resident was observed with another resident with their fists up, and the resident reported that the other resident threatened to hit their genitals, but again, no physical contact was made. Despite these incidents, the Director of Nursing reported that no investigations were conducted because there was no physical contact between the residents. This inaction is contrary to the facility's policy, which mandates that all reports of abuse, including verbal threats, be promptly and thoroughly investigated. The policy defines verbal abuse as the use of language that includes threats of harm, regardless of the resident's ability to comprehend. The lack of investigation into these incidents resulted in a deficiency, as the facility did not adhere to its own policy to ensure the safety and well-being of its residents.
Failure to Address Safety Concerns in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address safety concerns for a resident with dementia, identified as R3. R3 was admitted with a primary diagnosis of dementia and exhibited short- and long-term memory problems, as well as severely impaired cognitive skills for daily decision-making. An observation revealed R3 seated in a reclining wheelchair with a call light positioned near her knee, and no staff present. A clinical progress note from earlier in the year documented an incident where R3 wrapped a call light cord around her neck, requiring intervention from CNA staff. Despite this incident, R3's care plan did not include any focus area or interventions related to her behavior or the need for frequent safety checks. Interviews with facility staff, including a CNA and an RN, confirmed that R3 was impulsive and unaware of her own safety needs, necessitating frequent safety checks and keeping her near the nurses' station during waking hours. However, these safety measures were not documented in R3's care plan. The lack of a comprehensive care plan addressing R3's specific safety needs resulted in the potential for unmet safety needs, as the facility did not formally recognize or plan for the resident's impulsive behavior and safety risks.
Failure to Administer Supplemental Oxygen Per Physician Orders
Penalty
Summary
The facility failed to administer supplemental oxygen per physician orders for a resident with chronic respiratory failure and hypoxia. The resident, who had intact cognition, was observed multiple times without her prescribed supplemental oxygen, despite having an order for continuous oxygen at 2 liters and up to 6 liters with exertion. On one occasion, a registered nurse noticed the resident had removed her oxygen and did not take immediate action to reapply it, instead stating they would see how she did without it. The resident's electronic medical record confirmed the need for continuous oxygen, and there was no documented physician order to trial weaning off the oxygen. Interviews with staff revealed a misunderstanding or lack of adherence to the resident's oxygen requirements. A CNA mentioned that the resident's oxygen saturation was at 97% on room air, leading them to try without supplemental oxygen. An RN stated they were told to wean the resident off oxygen during the day but could not provide a physician's order for this action. The Director of Nursing and Clinical Care Coordinator confirmed that continuous supplemental oxygen should be worn at all times if ordered, and there was no communication in the resident's record to support the cessation of oxygen. The facility's policy on oxygen delivery did not include expectations regarding physician orders on oxygen weaning.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to assess and manage pain for a resident who was admitted with diagnoses including hypomagnesemia, acute pain due to trauma, and contusion of the left hip and knee. The resident, who had intact cognition, repeatedly complained of painful leg cramps and muscle spasms that disrupted her sleep. Despite these complaints being documented in the resident's electronic medical record (EMR) and communicated to the facility's clinical team, there was no follow-up or intervention by a physician to address her pain. The resident's daughter also contacted the primary care provider, expressing concerns about the lack of pain management for her mother. However, the primary care provider indicated that the resident was under the care of the facility's attending provider. An interview with the Clinical Care Coordinator/Registered Nurse revealed that the usual process for addressing such complaints was not followed, as the physician communication form was either lost or not properly transcribed. This resulted in the resident's pain going untreated, contrary to the facility's policy on aggressive pain prevention and management.
Failure to Conduct Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to appropriately conduct a gradual dose reduction (GDR) for a psychotropic medication for a resident diagnosed with dementia with behavioral disturbances and delusional disorders. The resident was admitted with a moderately impaired cognition score. The Consultant Pharmacist's Medication Regimen Review recommended a GDR evaluation for the resident's olanzapine, an antipsychotic medication, but the facility did not document any evaluation or rationale for not performing the GDR. The resident continued to receive the same dosage of olanzapine without any documented attempt at dose reduction or clinical contraindication. The Nursing Home Administrator acknowledged awareness of the GDR recommendation but cited issues with medical providers' understanding of GDR attempts per regulations. The facility's policy requires GDR attempts within the first year of admission or after initiation of a psychotropic medication, unless clinically contraindicated, with documentation in the clinical record. However, there was no evidence in the resident's electronic medical record that the facility addressed the pharmacist's recommendation or documented any clinical reasoning for not attempting a GDR.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a rate of 6.45 percent. This was due to two errors identified out of 31 opportunities, affecting one resident. The first error occurred when a registered nurse (RN) was unable to administer a scheduled dose of gabapentin 800 mg to a resident because the medication was not available in the automatic dispensing cabinet. The RN did not follow the facility's policy to notify the pharmacy for a refill, and the missed dose was inaccurately documented as administered in the Medication Administration Record (MAR). The second error involved the administration of insulin using a Humalog KwikPen. The RN failed to prime the pen before administering the insulin, which is necessary to ensure the correct dosage is delivered. The RN was unaware of the priming requirement until after the administration, which was confirmed upon reviewing the manufacturer's instructions. These actions and inactions led to the medication administration errors, contributing to the facility's failure to meet the required error rate standard.
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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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