Optalis Health And Rehabilitation Of Three Rivers
Inspection history, citations, penalties and survey trends for this long-term care facility in Three Rivers, Michigan.
- Location
- 517 S Erie St, Three Rivers, Michigan 49093
- CMS Provider Number
- 235395
- Inspections on file
- 30
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Three Rivers during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering was pushed by another resident with paranoid schizophrenia and aggressive behaviors after entering the latter's room, resulting in a hip fracture that required surgery. The incident occurred despite documented histories of wandering and aggression, and staff reports of feeling unsafe around the aggressive resident. Care plans included general interventions for wandering and behavior, but there was no evidence of targeted supervision or measures to prevent such altercations.
A resident with severe cognitive impairment was transferred to the hospital for a femoral neck fracture, but the facility did not provide a written bed hold notice to the resident's representative or document any follow-up communication in the medical record. Staff interviews revealed inconsistent practices, and the responsible party reported not being informed about the bed hold policy, contrary to facility policy requirements.
A resident with severe dementia was abruptly discharged to a locked memory care unit without adequate individualized interventions or proper notice, despite manageable behaviors and established routines that supported his well-being. The facility failed to implement new strategies to address concerns about interactions with other residents and did not provide the resident's representative with an opportunity to appeal the discharge. After the transfer, the resident experienced increased anxiety, agitation, and required additional psychotropic medications.
A resident with severe dementia was subjected to repeated verbal threats, insults, and mocking by another cognitively intact resident with a history of mental health issues. Staff, including the DON and NHA, were aware of the ongoing abuse but did not conduct an investigation or implement interventions to protect the targeted resident, despite the facility's abuse policy defining such actions as abuse.
Staff observed and reported that a cognitively intact resident engaged in repeated verbal aggression and bullying toward a resident with severe cognitive impairment, including threats and mocking in common areas. Multiple staff, including CNAs and an activity aide, reported these incidents to the DON and NHA, but the facility did not consider the actions to be abuse and failed to report the allegations to the State Agency as required by policy.
Two residents were involved in a situation where one, who was cognitively intact, verbally threatened another resident with severe cognitive impairment. Staff and a family member reported ongoing verbal threats and targeting of the cognitively impaired resident, but the DON and NHA did not conduct a thorough investigation as required by facility policy, failing to interview all involved or obtain written statements.
A resident with severe cognitive impairment and dementia was discharged without proper written notification to their DPOA. The DPOA was only informed by phone of the need to transfer the resident and was not given information about the right to appeal or the voluntary nature of the discharge, contrary to facility policy requiring written notice and explanation of appeal rights.
Two residents with behavioral and cognitive needs did not have individualized, person-centered care plan interventions reflecting their current conditions. One resident with anger management issues and another with severe cognitive impairment and wandering behaviors were not properly monitored or had their care plans updated, despite staff and family awareness of their needs.
The facility failed to provide medically related social services for two residents, resulting in a lack of advocacy for one resident's rights and insufficient individualized behavior management and discharge planning for both. One resident with dementia was transferred without proper interventions or documentation, while another resident with mental health diagnoses made threats without specific care plan updates. The absence of a dedicated social worker contributed to these deficiencies.
The facility did not maintain accurate and complete medical records for two residents, failing to document significant behavioral incidents, monitoring needs, and discharge notifications. Staff interviews revealed unrecorded behavioral issues and wandering, while care plans and monitoring reports did not reflect these events. Required written discharge notification was also not provided or documented for one resident.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient protective measures and oversight.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized as required.
A resident did not receive the medically-related social services needed to support their highest possible quality of life, as required by regulations.
A resident with severe cognitive impairment was found restrained in a wheelchair with a gait belt, contrary to her care plan, at a nurse's station. Staff interviews revealed that an LPN placed her there to prevent falls, but denied using a gait belt. The resident identified the LPN as the one who restrained her, leading to a deficiency citation for unauthorized restraint use.
The facility failed to prevent the misappropriation of narcotic medications for two residents. A nurse administered an incorrect dosage of Morphine Sulfate to a resident, using medication from another resident's card. Additionally, a discrepancy in Lorazepam administration was found, with a missing tablet and improper narcotic count verification by night nurses. The facility's policy on controlled medications was not followed, leading to medication errors and potential misappropriation.
The facility failed to document medication administration for two residents, leading to potential issues with controlled substances. A resident received Alprazolam without immediate documentation by an LPN, and another resident's Morphine administration was not recorded by an RN. This lack of adherence to documentation standards was confirmed by the ADON and DON.
A resident with cognitive impairment and a history of depression was hospitalized with aspiration pneumonia after the facility failed to assess and treat his change of condition. Despite complaints of dizziness, fatigue, and lack of appetite, there were no medical evaluations or vital signs documented for several days. The Medical Director was unaware of the resident's symptoms due to a lack of communication and documentation, leading to a delay in appropriate medical intervention.
A facility failed to remove a discharged resident's Morphine from the medication cart, resulting in another resident receiving an incorrect dosage. A nurse mistakenly administered two 30 mg Morphine tablets instead of the prescribed 45 mg, due to using the discharged resident's medication. The error was not fully realized by the DON, and the facility's medication disposal policy was not followed.
A resident with severe cognitive impairment and osteoporosis suffered a femur fracture, which was not reported to the State Agency within the required two-hour timeframe. The injury was discovered during a transfer, and although the physician suspected it might be pathological, there was no documentation to support this, nor was a full investigation conducted to rule out mistreatment. The facility's delay in reporting and lack of investigation highlight deficiencies in their processes.
The facility was cited for multiple deficiencies in food safety and equipment maintenance, affecting 82 residents. Observations revealed severely soiled food service equipment, improper date marking of ready-to-eat foods, and malfunctioning dishwashing equipment. These issues increase the risk of cross-contamination and foodborne illness.
The facility failed to implement comprehensive care plans for six residents, leading to potential unmet needs. A resident's smoking supplies were not secured as per policy, and another resident's fall risk intervention was not followed. Additionally, four residents with COVID-19 lacked care plans for isolation and infection management, despite precautions being indicated. Staff interviews revealed gaps in policy awareness and communication.
The facility failed to provide consistent showers and bathing to several residents, leading to unmet personal hygiene needs. A resident with multiple health issues did not receive scheduled showers due to a COVID outbreak, while another was left with long toenails and soaked in bed due to inadequate toileting assistance. A double amputee reported not receiving showers during isolation, and a cognitively intact resident experienced infrequent bed baths and inadequate hair washing. Staffing shortages and mismanagement were cited as reasons for these deficiencies.
The facility experienced significant staffing shortages, particularly on weekends, leading to unmet care needs for residents. Despite using agency staff and management covering shifts, the facility struggled to maintain adequate staffing levels. Residents reported not receiving showers, and staff confirmed that care tasks were incomplete due to insufficient staff. The administration was aware of the issue, but the lack of proper training for new staff and consistent call-ins exacerbated the problem.
The facility did not complete annual competency evaluations for three CNAs, potentially leading to unmet resident care needs. Evaluations were conducted electronically, with the DON responsible for completion. Notifications were sent to the DON and CNAs, but one evaluation was not completed, and two were not acknowledged by the CNAs.
The facility failed to secure medications in two of four medication carts, as observed on multiple occasions. The C Hall cart was found unlocked and unattended twice, with Agency RNs on their first day responsible. The A Hall cart was also found unlocked and unattended, violating the policy to lock carts when not in direct view of the administering nurse.
The facility failed to implement effective infection control measures, leading to potential cross-contamination and the spread of COVID-19. Observations showed inadequate signage and PPE availability, with staff not consistently adhering to PPE protocols. Specific incidents included staff entering COVID-positive rooms without proper PPE, contributing to infection risks. Residents with complex medical histories were affected, highlighting the facility's failure to maintain Enhanced Barrier Precautions.
The facility failed to maintain a clean and safe environment, affecting 82 residents. Observations revealed soiled areas, missing safety features, and multiple maintenance issues in common areas and resident rooms. The facility's maintenance and cleaning policies were not adhered to, with no work orders addressing these concerns. Additionally, unsmoothed spackling and a bare mattress were noted in a resident room.
The facility failed to promote dignity and respect for two residents, leading to potential feelings of diminished self-worth and anxiety. A resident with severe cognitive impairment was observed in a state of undress and without meal assistance, compromising his dignity. Another resident, on COVID-19 precautions, experienced increased anxiety due to her request to have her room door open being denied, despite her fear of dying alone. The facility's actions and inactions did not adequately address the residents' needs for privacy and emotional support.
A facility failed to assess a resident's ability to self-administer medication, leaving pills at the bedside without proper evaluation. The resident, with multiple health conditions and a BIMS score indicating cognitive intactness, was unsure about her medications. Staff interviews revealed that an assessment was required but not completed, and the care plan lacked necessary documentation. The DON confirmed that no residents were approved to self-administer medications.
Two residents expressed anger and frustration after a facility moved vending machines to an employee break room, restricting resident access. This decision was made due to concerns about dietary adherence, but it affected residents who were cognitively intact and had no dietary restrictions prohibiting vending machine use. Staff interviews revealed a lack of awareness and communication about the decision.
The facility failed to update care plans for two residents after changes in their conditions. One resident's care plan did not reflect current dietary orders and discontinued medication, while another resident's care plan did not address her refusal to have blood sugar checks despite receiving insulin. This resulted in inaccuracies in their care plans, as acknowledged by the DON.
A facility failed to implement and update fall prevention interventions for a resident with a history of falls and medical conditions such as diabetes and stroke. The care plan required the bed to be in a low position, but the resident experienced multiple falls without injury, and no new interventions were added. During an observation, the bed was not in the lowest position, and a CNA was unaware of the resident's need for posey hipsters, indicating non-compliance with the care plan.
A facility failed to offer a pneumococcal vaccine to a resident who was eligible and due for the vaccine upon admission. The resident, who was cognitively intact and had diagnoses of type 1 diabetes, anxiety, and depression, did not have a pneumonia vaccine documented in their immunization records. The Infection Preventionist confirmed that the vaccine was not offered, and there were no signed consents or declination documented. The facility's policy required evaluation and offering of the vaccine upon admission, with informed consent to be documented, which was not followed in this instance.
The facility failed to offer COVID-19 vaccinations to three residents, increasing the risk of severe infection. A resident with a history of heart failure requested a booster for months but did not receive it, leading to severe symptoms after testing positive. Two other residents, both cognitively intact, were not offered the vaccine upon admission, with no documentation of consent or declination. The facility's policy to offer and document COVID-19 vaccinations was not followed.
The facility failed to ensure a CNA completed the required 12-hours of annual in-service training, potentially leading to unmet resident care needs. The HR/P representative and Clinical Coordinator confirmed that department managers were responsible for tracking training completion, but documentation for one CNA was missing, indicating non-compliance with training requirements.
A resident experienced anger and frustration due to a delay in mail delivery caused by the previous administrator's failure to sort and distribute mail on time. The mail was locked in the administrator's office for several days, delaying the resident's receipt of a package. The issue was resolved after the administrator's departure, with daily mail delivery resuming.
The facility was found to have multiple safety and sanitation issues, including broken tiles, soiled ventilation screens, peeling flooring, and exposed sharp edges. Staff interviews revealed resident complaints about cleanliness, and the need for environmental improvements was acknowledged by the staff, including the DON and Maintenance Director.
A resident with moderate cognitive impairment and a history of heart and lung conditions was unable to access $80 from her trust account to pay important bills, causing her anxiety and frustration. The facility, lacking a full-time Business Office Manager, struggled to maintain enough cash for resident withdrawals, leading to the denial of the resident's request. The facility's policy required withdrawals to be available within three working days, which was not met.
A resident's lock box containing $152 was lost due to the facility's failure to prevent misappropriation of property. Despite having a care plan that included a lock box for safekeeping, the resident's money went missing, leading to feelings of frustration and helplessness. The resident expressed concerns about the security of her belongings, affecting her trust in the facility and her overall well-being. Investigations by the facility and police did not identify a suspect.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent resident-to-resident abuse, resulting in a resident with dementia and severe cognitive impairment being pushed by another resident with a history of paranoid schizophrenia, delusions, hallucinations, and aggression. The incident occurred when the cognitively impaired resident, who had a documented history of wandering and entering other residents' rooms, was found on the floor outside the aggressive resident's room after being pushed. The injured resident sustained a closed left femoral neck fracture, requiring surgical intervention and a subsequent decline in functional status, now needing assistance with activities of daily living and ambulation. Prior to the incident, the resident with dementia was known to wander independently throughout the facility and had been documented as entering or lingering near other residents' rooms on multiple occasions. The care plan for this resident included interventions for wandering and cognitive impairment, but these primarily focused on redirection, encouragement to attend activities, and non-pharmacological interventions. Staff interviews revealed that the resident required frequent reminders not to enter other residents' rooms due to her memory deficits, and that she did not regularly participate in group activities, preferring to spend time alone. The resident who pushed the other had a well-documented history of delusions, paranoia, and aggressive behaviors, including previous incidents of threatening staff, refusing care, and expressing fears of being harmed or poisoned. Staff and behavioral logs indicated that this resident had exhibited threatening and unpredictable behavior on several occasions, and some staff reported feeling unsafe when providing care. Despite these known risks, there was no evidence of enhanced supervision or specific interventions to prevent resident-to-resident altercations between these two individuals prior to the incident.
Failure to Provide and Document Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to the resident's representative when the resident was transferred to the hospital, and did not document any follow-up communication or attempts in the resident's medical record. The resident, who had dementia and severe cognitive impairment, was transferred to the hospital for a femoral neck fracture requiring surgery. Interviews with facility staff revealed inconsistent practices regarding the distribution and documentation of bed hold notices, with some staff stating that the notice is sent with the resident and others indicating that follow-up calls are made to the responsible party. However, there was no evidence in the resident's chart of a bed hold notice being provided or any follow-up attempts documented. The facility's own policy requires that upon a resident's transfer for hospitalization, written notice specifying the bed hold policy must be provided to the resident and their representative, and that attempts to contact the representative and their decision regarding the bed hold must be documented in the resident's record. In this case, the responsible party reported not being informed about the bed hold policy at the time of transfer, and the facility was unable to provide documentation that the required notice or follow-up occurred. This resulted in the potential for the resident and/or their representative to be uninformed about the bed hold policy during the hospital transfer.
Failure to Prevent Unnecessary and Abrupt Discharge of Resident with Dementia
Penalty
Summary
The facility failed to prevent an unnecessary and abrupt discharge of a resident with dementia, resulting in significant emotional distress and increased behavioral symptoms. The resident, who was severely cognitively impaired and had a history of dementia with behavioral disturbances, was familiar with the facility environment and had established routines that helped manage his anxiety and agitation. Despite this, the facility's interdisciplinary team, including the Nursing Home Administrator and Director of Nursing, decided to seek a transfer for the resident due to concerns about his wandering and interactions with other residents, particularly after another resident verbally threatened him. However, the only intervention implemented was increased staff supervision as available, and there was no evidence of individualized care or additional interventions to address the situation within the facility. Interviews with staff indicated that the resident's behaviors were manageable and that he was easily redirected. The care plan included strategies such as involving the resident in one-on-one activities and maintaining a predictable routine, but there was no documentation of new or enhanced interventions to address the reported concerns. The resident's representative was not given the option to appeal the discharge and was only informed of the transfer on the day it occurred. The facility did not provide documentation of efforts to address the behaviors of the other resident who was threatening the discharged resident, nor did they pursue additional resources or support due to the absence of a social worker at the time. Following the abrupt transfer to a locked memory care unit, the resident experienced increased anxiety, agitation, and emotional distress, requiring pharmacological intervention. Reports from the receiving facility and the resident's representative indicated that the resident became physically aggressive, more combative, and required multiple psychotropic medications to manage his intensified behaviors. The facility's discharge policy required specific documentation and notice, including the basis for discharge and efforts to meet the resident's needs, but there was no evidence that these requirements were met. The lack of individualized care and failure to prepare the resident for a safe and appropriate transfer led to significant psychosocial harm.
Failure to Protect Resident from Ongoing Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, specifically in the case involving two residents. One resident, who was cognitively intact but had a history of borderline intellectual functioning, bipolar disorder, and anxiety, repeatedly directed verbal threats, insults, and mocking toward another resident with severe dementia. Multiple staff members, including the DON and NHA, were aware of these incidents, which included threats of physical harm and derogatory remarks made in public areas of the facility. Staff interviews confirmed that the abusive resident regularly made such statements and that these interactions were ongoing. The resident who was the target of the abuse had severe cognitive impairment due to dementia and was unable to fully express his feelings about the incidents. However, his DPOA and staff noted that he would become emotionally upset if spoken to harshly. The care plan for this resident included interventions for managing anxiety and agitation, but there was no evidence that specific measures were implemented to address the ongoing verbal abuse from the other resident. Staff acknowledged that the abusive behavior was a continuous issue and that the resident with dementia was being targeted, but no formal investigation or documentation of interventions was completed. Despite multiple reports and observations of the abusive behavior, including threats and public humiliation, the facility did not take adequate steps to investigate or prevent further incidents. The DON and NHA both confirmed their awareness of the situation but did not initiate an investigation or implement new interventions to protect the resident with dementia. The facility's own abuse policy defined such verbal threats and mocking as mental and verbal abuse, yet the response from staff was insufficient to ensure the resident's safety and dignity.
Failure to Report Alleged Verbal and Mental Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, was reported by multiple staff members and another resident to have engaged in verbally aggressive and bullying behavior towards another resident with severe cognitive impairment due to dementia. Incidents included yelling, making threats, mocking, and making derogatory comments in the dining room, which were witnessed by several staff members including CNAs, an activity aide, and a nurse. These behaviors were discussed among staff and in interdisciplinary team meetings, but were not taken seriously or escalated as abuse allegations. Staff interviews revealed that the bullying and verbal aggression were reported to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at the time of the incidents. Despite these reports, the DON and NHA did not consider the actions to constitute abuse, as there was no physical contact, use of profanity, or apparent harm. As a result, no report was made to the State Agency as required by facility policy and federal regulations, which mandate immediate reporting of all allegations of abuse, including verbal and mental abuse, regardless of perceived severity or outcome. The facility's own policy defined mental and verbal abuse to include harassment, mocking, insulting, ridiculing, yelling, or threatening behavior, and required immediate reporting of such allegations to the administrator and the State Survey Agency. The failure to report these incidents, despite multiple staff being aware and the behaviors fitting the policy's definition of abuse, constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. One resident, who was cognitively intact and had diagnoses including borderline intellectual functioning, bipolar disorder, and anxiety, verbally threatened another resident in the dining room. This incident was witnessed by an activity aide, who reported it to both the Director of Nursing (DON) and the Nursing Home Administrator (NHA), but was not asked to provide a written statement. The resident who was threatened had severe cognitive impairment due to dementia and other medical conditions. Multiple staff members and a family member reported that this resident was being targeted and verbally threatened by a group of residents, including the resident who made the threat. Despite these reports, the DON and NHA did not conduct a thorough investigation. The DON stated that the information provided did not indicate abuse and therefore did not warrant further investigation. The NHA recalled only a brief, in-the-moment inquiry and did not remember the incident reported by the activity aide. The facility's policy requires investigation of all alleged violations, including interviewing all involved persons and witnesses, but this was not followed. As a result, the potential for the allegation to not be thoroughly investigated and for further abuse to occur remained.
Failure to Provide Written Discharge Notification and Appeal Rights
Penalty
Summary
The facility failed to provide proper written discharge notification to a resident's Durable Power of Attorney (DPOA) during the discharge process. The resident, who had a diagnosis of dementia with behavioral disturbance and was assessed as severely cognitively impaired, was abruptly discharged from the facility. The DPOA reported receiving only a telephone call from the Admissions Coordinator informing her that the resident needed to be transferred to another skilled nursing facility and was instructed to come immediately to transport the resident. The DPOA was not given the option to appeal the discharge and was not informed that the discharge was voluntary. Upon arrival at the facility, the DPOA was told by the Nursing Home Administrator that the resident was being harassed by another resident and had to leave. The Nursing Home Administrator later confirmed that no written notification of discharge, including the rationale for discharge and information about appeal rights, was provided to the DPOA at the time of the resident's discharge. Facility policy requires that such notice be given to both the resident and their representative, including the specific reason for discharge, explanation of appeal rights, and information on how to obtain and submit an appeal form.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, individualized care plan interventions for two residents, resulting in the potential for unmet needs. One resident, a female with borderline intellectual functioning, bipolar disorder, and anxiety, was cognitively intact but reported significant anger management issues, particularly towards another resident. Despite her expressed concerns about her anger and interactions with another resident, the care plan only included general interventions for suspiciousness and did not address her specific behavioral concerns or the recent escalation in her anger. Interviews with staff revealed a lack of awareness and monitoring of her behaviors, and there was no clear documentation or update to her care plan following incidents involving the other resident. Another resident, a male with dementia, a history of stroke, and joint replacement, was severely cognitively impaired and exhibited frequent wandering behaviors. He was known to wander the facility, was easily redirectable, and often entered other residents' rooms due to confusion about his own room location. Family and staff interviews confirmed his wandering as a baseline behavior and a means of stress relief. However, his care plan did not reflect his wandering, inability to locate his room, or his tendency to enter other residents' rooms, despite these behaviors being well-documented in progress notes and staff observations. The deficiency was further evidenced by interviews with various staff members, including CNAs, RNs, and LPNs, who either were unaware of the need to monitor the first resident for behavioral issues or confirmed the second resident's wandering without corresponding care plan interventions. The lack of updated, individualized care plans for both residents demonstrated a failure to ensure that care plans were comprehensive, person-centered, and responsive to the residents' current needs and behaviors.
Failure to Provide Medically Related Social Services and Individualized Behavior Management
Penalty
Summary
The facility failed to provide medically related social services to support the mental and psychosocial health of two residents. One resident with dementia and severe cognitive impairment was subject to a transfer process initiated by the facility's interdisciplinary team due to concerns about his interactions with other residents. The resident's care plan did not include interventions related to wandering or maintaining his safety around other residents who were frustrated by him. Documentation showed no social work interventions, and the resident's representative was not informed of the right to appeal the discharge or that the discharge was voluntary. Staff interviews revealed that interventions to address the resident's behaviors and safety were limited to increased supervision, with no evidence of individualized behavior management or documentation of these actions. Another resident, who was cognitively intact but had a history of borderline intellectual functioning, bipolar disorder, and anxiety, expressed difficulty managing anger and reported making verbal threats toward the first resident. The care plan for this resident included general interventions for suspiciousness and coping but did not address the specific issue of threatening or harassing other residents. Staff interviews indicated that interventions were limited to attempts to keep the residents separated and verbal communication among staff, with no clear documentation or care plan updates regarding these behaviors. During the period in question, the facility did not have a dedicated social worker, and social work responsibilities were handled by nursing staff and a corporate-level social worker who was not involved in the care planning or discharge planning for the affected residents. The lack of social work involvement resulted in insufficient advocacy for residents' rights, inadequate individualized behavior management interventions, and incomplete discharge planning, as evidenced by the absence of documented interventions and care plan updates.
Failure to Maintain Accurate Medical Records and Discharge Documentation
Penalty
Summary
The facility failed to maintain clear and accurate medical records for two residents, resulting in incomplete documentation of behaviors, care needs, and discharge processes. For one resident with a history of borderline intellectual functioning, bipolar disorder, and anxiety, there was no documentation in the medical record regarding a reported yelling incident and ongoing behavioral issues, despite staff interviews indicating repeated behavioral concerns and a care plan that included monitoring for such behaviors. Multiple staff members were either unaware of the need to monitor this resident or reported no behaviors observed, and behavior monitoring reports did not reflect the incidents described by staff. For another resident with dementia and behavioral disturbances, the medical record did not accurately document wandering behaviors, exit-seeking, or the resident's inability to locate his room, even though several staff and family interviews confirmed these behaviors were frequent and escalating prior to discharge. The care plan and behavior monitoring reports failed to include or reflect these significant behaviors, and documentation of wandering was notably absent despite it being an available option in the monitoring system. Additionally, when this resident was discharged due to increased behavioral needs that could not be met at the facility, there was no written notification of discharge provided to the resident's representative, and this documentation was not uploaded into the medical record as required by facility policy. The provider discharge summary also lacked specific details about the behaviors leading to discharge and the rationale for transfer, further contributing to the incomplete and inaccurate medical record.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to address their individual needs and promote their well-being.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to prevent the use of physical restraint on a resident, identified as Resident #100, who was found confined in a wheelchair with the brakes locked against the nurse's station. The resident, who was severely cognitively impaired with a BIMS score of 5/15, was admitted with diagnoses including unspecified psychosis, vascular dementia, and generalized anxiety disorder. Despite being able to walk independently, the resident was placed in a wheelchair and restrained with a gait belt, which was not part of her care plan. On the night of the incident, LPN S discovered Resident #100 restrained in a wheelchair and emotionally upset, unable to remove the gait belt. LPN S reported the situation to DON B, who instructed her to release the resident and conduct a skin and pain assessment. Interviews with staff revealed that LPN Z had placed the resident in the wheelchair to prevent falls, but denied using a gait belt. CNA E and CNA H also provided accounts of the resident's restlessness and the challenges in supervising her due to staffing constraints. The investigation summary indicated that Resident #100 identified LPN Z as the person who placed the gait belt on her. Despite the resident's cognitive impairments, the report suggests that any reasonable person would experience emotional distress from being physically restrained. The facility's failure to adhere to the resident's care plan and prevent the use of unauthorized restraints resulted in a deficiency citation.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of scheduled narcotic medication for two residents, resulting in the potential for ongoing misappropriation of narcotic medications. For one resident, a nurse mistakenly administered a 30 mg Morphine Sulfate tablet from another resident's medication card, who had been discharged from the facility. This resulted in the resident receiving an incorrect dosage of 60 mg instead of the prescribed 45 mg. The nurse involved acknowledged the error and reported it to the supervisor, but the Director of Nursing (DON) did not conduct a further investigation into the medication misappropriation. In another incident, a discrepancy was found in the administration of Lorazepam for a different resident. The Controlled Drug Receipt/Record/Disposition Form indicated that a tablet was missing, and the DON's investigation revealed that two night nurses did not appropriately verify the narcotic count before administering medication. A pill resembling Lorazepam was found under the narcotic drawer, but it was not confirmed if it was the missing medication. The facility's policy on controlled medications was not followed, as the narcotic count was not consistently verified by the nurses involved. The facility's policy requires a physical inventory of all controlled medications to be completed by two licensed nurses, but this was not adhered to. The report highlights that the night nurses shared a medication cart and narcotic drawer, which led to confusion and lack of accountability. The failure to follow proper procedures for handling and documenting controlled substances resulted in medication errors and potential misappropriation, as evidenced by the discrepancies in the narcotic counts and administration records.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to nursing professional standards related to the documentation of medication administration for two residents, resulting in potential issues with controlled substances and medication accuracy. Resident #206, who was cognitively intact and had a history of anxiety disorder, was observed to have received Alprazolam at noon on April 2, 2025. However, the LPN responsible for administering the medication did not document the administration on the disposition form at the time of administration, as confirmed by the Assistant Director of Nursing. This lapse in documentation is against the standard practice of signing out medications immediately after administration. Similarly, for Resident #110, the facility failed to document the administration of Morphine Sulfate Oral Solution on the Medication Administration Record, despite the medication being signed out by an agency RN on multiple occasions. The RN confirmed that the medication was not documented as administered, and the Director of Nursing reiterated the importance of documenting medication administration in the Medication Administration Record to confirm it was given. The facility's policy on controlled medication guidelines requires documentation of both the removal and administration of controlled medications, which was not adhered to in these instances.
Failure to Assess and Treat Resident's Change of Condition
Penalty
Summary
The facility failed to comprehensively assess and prescribe appropriate treatment for a resident who was hospitalized with aspiration pneumonia. The resident, who was moderately cognitively impaired and had a history of major depressive disorder, reported symptoms such as vertigo, dizziness, fatigue, and lack of appetite. Despite these complaints, there was no documentation of medical evaluations, nursing assessments, or vital signs recorded for the resident between January 21 and January 27, 2025. Interviews revealed that the resident had expressed feeling unwell to several staff members and had episodes of vomiting and coughing, which were not communicated to the Medical Director. The Medical Director admitted to being behind on documentation and was unaware of the resident's coughing during meals, a potential indicator of aspiration risk. The resident was eventually sent to the hospital for a psychiatric evaluation but was admitted for medical reasons due to pneumonia and other acute conditions. The facility's Change of Condition policy requires staff to notify a licensed nurse of any significant deviations from a resident's baseline condition. However, the lack of communication and documentation led to a failure in recognizing and addressing the resident's medical needs, resulting in hospitalization for aspiration pneumonia and other acute illnesses.
Failure to Properly Dispose of Discharged Resident's Medication Leads to Error
Penalty
Summary
The facility failed to properly remove and dispose of controlled substance medication for a discharged resident, leading to a medication error. A resident, who was discharged, had their Morphine sulfate ER 30 mg tablets left in the medication cart instead of being removed and stored securely. This oversight resulted in another resident receiving an incorrect dosage of Morphine. Specifically, a nurse mistakenly administered two 30 mg Morphine tablets to a resident instead of the prescribed 45 mg, due to pulling a 30 mg dose from the discharged resident's medication card. The error was compounded by the fact that the nurse did not realize the mistake until after the medication was administered, and the Director of Nursing (DON) was unaware of the full extent of the error. The resident who received the incorrect dosage was experiencing pain from a pressure ulcer and continued to request additional pain medication. The facility's policy on medication disposal was not followed, as the discharged resident's medication was not promptly removed from the cart and stored in the medication room safe, leading to the potential for diversion or misappropriation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure the timely identification and reporting of an injury of unknown origin for a resident, resulting in a potential risk for unidentified abuse or neglect. The resident, a female with severe cognitive impairment and a history of osteoporosis and vascular dementia, was found to have a fracture in her left femur. The injury was discovered when the resident complained of pain during a transfer to bed, and an X-ray confirmed the fracture. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the State Agency within the required two-hour timeframe. The incident was initially reported by a nurse to the Director of Nursing (DON) in the evening, who then contacted the physician. The physician suspected the fracture might be pathological due to the resident's medical history, and this was communicated to the DON. However, there was no documentation in the resident's medical record to support this determination at the time, and the facility did not conduct a full investigation to rule out mistreatment or inappropriate transfer as potential causes of the fracture. Interviews with facility staff revealed a lack of clarity and communication regarding the reporting requirements and the need for a thorough investigation. The Registered Dietitian and Nursing Home Administrator in Training submitted the Facility Reported Incident the following day, outside the required timeframe. The facility's failure to adhere to its policy and promptly report the injury as an injury of unknown source highlights a deficiency in their reporting and investigation processes.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies related to the cleanliness and maintenance of food service equipment, as well as the proper date marking of potentially hazardous ready-to-eat food products. During a comprehensive tour of the food service area, multiple pieces of equipment, including cutting boards, ovens, and a toaster, were observed to be severely soiled with accumulated and encrusted food residue. Additionally, the walk-in freezer and other refrigeration units were noted to have ice accumulation and soiled surfaces, which could contribute to cross-contamination and bacterial harborage. Further observations revealed that the facility's dishwashing equipment was not functioning properly, with temperature gauges reading below the required levels for effective sanitization. The mechanical dish machine's final rinse temperature gauge was observed at 122 degrees Fahrenheit, significantly lower than the required 180 degrees Fahrenheit. This issue was compounded by missing entries in the dishwasher log, indicating a lack of proper monitoring and maintenance of the equipment. The facility also failed to date mark ready-to-eat food products appropriately. Several items, including a gallon of milk and sandwiches stored in a refrigerator, were found without effective date marks, which is a violation of the FDA Model Food Code. These deficiencies highlight a failure to adhere to established food safety protocols, increasing the risk of foodborne illness among the 82 residents affected by these practices.
Deficiencies in Care Plan Implementation and Infection Control
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential unmet medical, physical, mental, and psychosocial needs. For Resident #46, the care plan indicated that smoking supplies should be stored in a locked box on a locked nursing cart, but observations revealed that the resident kept a lighter on his nightstand and stored cigarettes wherever he could hide them. Interviews with staff, including an agency LPN and the Director of Nursing, highlighted a lack of awareness and adherence to the facility's no-smoking policy, which required smoking supplies to be secured by nurses. Resident #29's care plan, which was revised to address fall risks, included an intervention to keep the bed in a low position. However, multiple observations showed that the resident's bed was not consistently kept low, contrary to the care plan. Interviews with a CNA and the Director of Nursing revealed that care plan updates were discussed in meetings, but the information was not effectively communicated or implemented in practice. For Residents #19, #42, #41, and #51, who tested positive for COVID-19, there were no care plans in place for droplet isolation or acute infection management. Despite the presence of STOP signs indicating COVID precautions outside their rooms, the charts lacked documentation of these precautions. The Infection Preventionist confirmed that care plans should be developed for residents with acute infections, but this was not done, indicating a gap in the facility's infection control practices.
Failure to Provide Consistent Hygiene Care
Penalty
Summary
The facility failed to consistently provide showers and bathing to five residents, leading to unmet personal hygiene needs. Resident #27, who had multiple health issues including diabetes and heart failure, was not receiving showers as scheduled due to a COVID outbreak in the facility. Despite the care plan indicating specific shower days, there was confusion among staff about the schedule, and family members reported inconsistencies in the provision of care. Resident #80, who had a history of falls and was at risk due to a previous stroke, was found with long toenails cutting into her skin and was often left soaked in bed. The care plan required regular toileting, but staff failed to assist her to the bathroom, leaving her in a state of neglect. Similarly, Resident #28, a double amputee with end-stage renal disease, reported not receiving showers or hair washing while on isolation precautions, and staff confirmed a lack of resources like shower caps. Resident #5, who was cognitively intact but had multiple health issues, reported infrequent bed baths and inadequate hair washing, leading to visible hygiene issues. Resident #57, also cognitively intact, had not received a shower in two weeks despite not being on isolation, with staff citing short staffing as the reason for missed showers. The facility's failure to provide adequate personal hygiene care was attributed to staffing shortages and mismanagement during a COVID outbreak.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing, resulting in unmet care needs for residents. Observations and interviews revealed that the facility was consistently short-staffed, particularly on weekends, leading to incomplete tasks such as resident showers and providing fresh water at the bedside. The facility had started using agency staff to cover open shifts, but issues with call-ins and staff not completing their shifts persisted, causing disruptions in the schedule. Management and other staff members had to cover shifts, but this was not enough to meet the residents' needs. Interviews with residents and staff highlighted the impact of the staffing shortages. Residents reported not receiving showers for extended periods, and staff confirmed that when short-staffed, showers and other care tasks were not completed. The facility's staffing requirements indicated a need for more CNAs on each hall than were often available, leading to inadequate care coverage. Staff also reported burnout due to the increased workload and lack of support, with some CNAs quitting or reducing their hours as a result. The facility's administration was aware of the staffing issues, as evidenced by a past noncompliance report. Despite efforts to use agency staff and management covering shifts, the facility continued to struggle with maintaining adequate staffing levels. The lack of proper training and orientation for new staff further exacerbated the situation, leaving them unprepared to meet the residents' needs effectively. The deficiency was evident in the consistent reports of unmet care needs and the facility's inability to provide adequate staffing to ensure resident care.
Failure to Complete Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that annual competency evaluations were completed for three certified nursing assistants (CNAs) out of five reviewed, which could potentially lead to unmet resident care needs. During a review of employee education files, it was found that no annual competency evaluations were present for the CNAs. Human Resources/Payroll (HR/P) reported that these evaluations were conducted electronically and that the Director of Nursing (DON) was responsible for completing them. Notifications were sent electronically to the DON when evaluations were due, and once completed, CNAs were notified to review them. However, one CNA's evaluation was completed and acknowledged by the manager but not by the CNA, another CNA's evaluation was not completed, and a third CNA's evaluation was completed and acknowledged by the manager but not by the CNA.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure medications were safely stored in two of four medication carts, leading to potential missing medications. On two separate occasions, the C Hall medication cart was observed unlocked and unattended, with no staff present nearby. On the first occasion, an Agency RN, who was on her first day at the facility, returned to lock the cart. On the second occasion, the Director of Nursing (DON) locked the cart, noting that the nurse on duty was also an Agency Nurse on his first day. Additionally, the A Hall medication cart was found unlocked and unattended, further indicating a lapse in adherence to the facility's policy requiring medication carts to be locked when not in direct view of the administering nurse.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement effective infection control measures to prevent the spread of COVID-19 and maintain Enhanced Barrier Precautions (EBP) for several residents. Observations revealed that there were inadequate signs indicating the appropriate personal protective equipment (PPE) to be worn, and PPE carts or bins were not available outside rooms. Staff interviews indicated a lack of consistent understanding and adherence to PPE protocols, with some staff not wearing the required N95 masks and face shields when entering COVID-positive rooms. Specific incidents included a Social Services Coordinator entering a COVID-positive room without a face shield and not sanitizing his glasses after exiting. A Licensed Practical Nurse (LPN) was observed entering a COVID-positive room without donning a face shield and continuing to work without changing her mask. Additionally, a Certified Nursing Assistant (CNA) entered a COVID-positive room without any PPE. These actions contributed to the potential for cross-contamination and the spread of infection within the facility. Resident #23, who had a history of heart failure and other conditions, was diagnosed with COVID-19 and experienced severe respiratory issues, leading to hospitalization and intubation. The resident reported not receiving a requested COVID booster shot. Resident #17, with a tracheostomy and traumatic brain injury, did not have an EBP sign on his door initially, and staff were unaware of the necessary precautions. Resident #51, who tested positive for COVID-19, had no order for COVID precautions in her chart, and staff were not consistently wearing face shields in COVID-positive rooms.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and the public, affecting 82 residents. Observations revealed that the oxygen storage building was soiled with dead leaves and debris, and the flooring was covered with dust and dirt. During a tour of the common areas, it was noted that the A-B Shower Room had a heavily soiled ventilation grill and a missing atmospheric vacuum breaker in one of the shower stalls. The C-D Shower Room had a leaking hand sink basin and pooling water on the floor. Additionally, the Floor Care Storage Room and Janitor Closet were in disarray and heavily soiled, and the Occupational Therapy/Physical Therapy Storage Room had a non-functional light assembly. Further inspections of resident rooms revealed multiple maintenance issues. In room A107, the hand sink basin was draining slowly, while room A109 had damaged drywall near the soap dispenser. Several rooms, including B102, B105, B109, B110, B113, C103, C106, and D105, had stained and cracked commode base caulking. Room B109 had a non-functional television, which a resident reported had been broken for eight months. Room B110 had a slow-draining sink and a malfunctioning PTAC unit, with the Director of Maintenance confirming that the unit's motherboard was fried and needed replacement. The facility's maintenance inspection and cleaning policies were reviewed, revealing a lack of adherence to these procedures. The TELS work order system showed no entries related to the identified maintenance concerns over the past 90 days. Additional observations included unsmoothed and unpainted spackling on the wall in room A112-1, a bare mattress in room A112-2, and a hole in the wall between the bathroom and closet doors. These deficiencies indicate a failure to provide a safe, functional, sanitary, and comfortable environment as per the facility's policies.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to promote dignity and respect for two residents, resulting in potential feelings of diminished self-worth, sadness, and anxiety. Resident #44, a male with severe cognitive impairment due to a stroke, was observed in a state of undress on multiple occasions. He was seen in his room with his private areas exposed due to an unsecured brief and without a shirt or pants. Additionally, he was observed in the dining room with food debris on his shirt and no staff present to assist him with his meal, further compromising his dignity. Resident #58, a female with dementia and other health issues, was placed on transmission-based precautions due to a COVID-19 diagnosis. Despite her expressed anxiety and fear of dying alone, her request to have her room door open was denied by the staff, citing infection control concerns. The resident's family member reported her anxiety and claustrophobia due to the closed door, but the staff did not accommodate her request, leading to increased anxiety for the resident. The facility's actions and inactions in these cases demonstrate a failure to uphold the residents' rights to dignity and self-determination. The observations and interviews indicate that the facility did not adequately address the residents' needs for privacy, assistance, and emotional support, contributing to their distress and anxiety.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure the safety of self-administration of medication for one resident, resulting in a potential risk for complications. The resident, who was cognitively intact with a BIMS score of 15, had multiple diagnoses including chronic respiratory failure, muscle weakness, and diabetes. During an observation, a registered nurse left a cup of pills at the resident's bedside after administering insulin injections, without confirming the resident's ability to self-administer the medication safely. The resident expressed uncertainty about the medications she was taking and their purposes. Interviews with staff revealed that the facility's policy required an assessment to determine if a resident could safely self-administer medications, which was not completed for this resident. The care plan lacked documentation regarding the resident's ability to self-administer medications, and no lock box was provided for safe storage. The Director of Nursing confirmed that medications should not be left at the bedside unless a resident is assessed as safe to self-administer, and no residents in the facility were currently approved to self-administer their medications.
Facility Fails to Honor Resident Choices by Restricting Vending Machine Access
Penalty
Summary
The facility failed to honor resident choices, impacting two residents who were reviewed for self-determination. Resident #14, who has Type 2 diabetes and is cognitively intact, expressed anger over the inability to access vending machines, which were moved to the employee break room, restricting resident access. This change was made despite Resident #14's dietary order for a cardiac/diabetic diet, which did not explicitly prohibit access to vending machines. Similarly, Resident #42, who is also cognitively intact and has an acquired absence of both legs above the knee, reported frustration over the same issue. The vending machines were relocated due to concerns about residents with special dietary needs not adhering to their diets. However, Resident #42 was on a regular diet and felt unjustly restricted. Interviews with facility staff, including the Maintenance Manager and Clinical Coordinator, revealed a lack of awareness and communication regarding the decision to move the vending machines, which was made by a previous management team.
Failure to Update Care Plans After Changes in Resident Conditions
Penalty
Summary
The facility failed to update or revise the comprehensive care plans for two residents after changes in their conditions, leading to inaccuracies in their care plans. Resident #44, who had severe cognitive impairment and a history of stroke, was observed with a care plan that did not reflect his current dietary orders. His care plan still indicated he was NPO (nothing by mouth) despite a physician's order allowing a regular diet with puree texture and thin consistency. Additionally, his care plan included a focus on the risk for bleeding due to Coumadin intake, even though the medication had been discontinued. Resident #14, who was cognitively intact and had Type 2 diabetes, had a care plan that failed to address her refusal to have her blood sugar checked. Despite receiving insulin injections multiple times a day, there were no documented blood sugar readings after a certain date, and her care plan did not reflect her refusal to have her blood sugar monitored. Interviews with staff revealed that blood sugar checks were not performed unless ordered by a provider or if the resident was symptomatic, and it was noted that Resident #14 frequently refused these checks. The deficiencies in the care plans for both residents resulted in an inaccurate reflection of their current medical needs and conditions. The Director of Nursing acknowledged that care plans should be updated by the Interdisciplinary Team with any changes in the resident's condition, but this was not done for Resident #44's discontinued medication and dietary changes, nor for Resident #14's refusal to have her blood sugar checked.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and update care planned interventions to maintain safety for a resident at risk for falls. The resident, a female with diagnoses including diabetes, stroke with left-sided weakness, and high blood pressure, had a care plan indicating the bed should be in a low position when in bed. Despite this, incident reports revealed multiple falls from bed without injury, and no additional interventions were added to prevent future falls. During an observation, the resident was found in bed with the wheelchair out of reach, and the bed was not in the lowest position. A CNA reported being unaware of the resident's need for posey hipsters and had never seen them, indicating a lack of adherence to the care plan and insufficient supervision to prevent accidents.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that pneumococcal vaccines were offered to a resident, identified as Resident #51, who was reviewed for pneumococcal vaccinations. This oversight resulted in the resident potentially acquiring and experiencing complications related to pneumonia. Resident #51 was admitted to the facility with diagnoses of type 1 diabetes, anxiety, and depression, and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A review of the resident's immunization records revealed the absence of a pneumonia vaccine, and there were no signed consents or declination of the vaccine documented in the resident's chart. During an interview, the Infection Preventionist confirmed that Resident #51 was due for a pneumonia vaccine and was not offered one upon admission. The facility's Vaccination-Pneumococcal Vaccine Policy, dated October 13, 2023, stated that residents would be evaluated for eligibility to receive the pneumococcal vaccine series upon admission and offered the vaccine unless medically contraindicated or already immunized. The policy also required informed consent to be documented in the resident's medical record, which was not done in this case.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to three residents, resulting in an increased likelihood of severe infection and complications related to COVID-19. Resident #51, who was cognitively intact, tested positive for COVID-19 and had not been offered a current COVID-19 vaccine upon admission. Her immunization records showed her last booster was in 2022, and there was no documentation of consent or declination for the current vaccine. Similarly, Resident #343, also cognitively intact, tested positive for COVID-19 and had not been offered the vaccine upon admission. Her last booster was in 2021, and there was no documentation of consent or declination for the current vaccine. Resident #23, with a history of heart failure and other significant health issues, had requested a COVID booster for months but did not receive it. She tested positive for COVID-19 and experienced severe symptoms, including intubation and weakness. Her immunization records showed her last booster was in 2022, and there was no documentation of consent or declination for the current vaccine. The facility's COVID-19 policy required offering the vaccine and documenting education and consent or declination, which was not followed in these cases.
Deficiency in CNA In-Service Training Completion
Penalty
Summary
The facility failed to ensure the completion of 12-hours of annual in-service training for one Certified Nursing Assistant (CNA) out of five reviewed, which could potentially lead to unmet resident care needs. During an interview, the Human Resource/Payroll (HR/P) representative reported that annual in-services are assigned at hire and then annually by the corporate office. However, the HR/P representative was unsure about the tracking of long-term staff training completion and stated that department managers were responsible for this task. The Clinical Coordinator (CC) confirmed that CNA in-services were provided through online modules and in-person training, and department managers should track completion. Despite this, the CC was unable to provide documentation for one of the CNAs, confirming that the CNA had not completed any assigned online education modules and did not meet the required 12-hours of in-service training.
Mail Delivery Delay Causes Resident Frustration
Penalty
Summary
The facility failed to ensure timely delivery of mail to a resident, resulting in feelings of anger and frustration. Resident #42, who is cognitively intact with a BIMS score of 15/15 and has an acquired absence of both legs above the knee, reported not receiving her mail for four days in August 2024. The mail delivery process involved the receptionist sorting the mail and notifying the activities department for distribution. However, during the period in question, the mail was first given to the nursing home administrator for logging before being passed to the activities department. On August 23, 2024, the activities department did not receive any resident mail because the previous administrator did not have time to sort it, resulting in the mail being locked in the administrator's office until the following week. This delay affected Resident #42, who had a package delivered to the facility but did not receive it until the following Monday. The issue was resolved after the previous administrator left, with mail and packages being delivered daily to residents.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of physical deficiencies and unsanitary conditions. During a tour, surveyors noted a broken tile with an unknown white material on the floor, heavily soiled ventilation screens, peeling laminate flooring, and dust-covered window coverings in the dining room. Additionally, the ceiling grid in the dining room had peeling paint hanging over resident dining tables, and the chair railing had deep gouges with jagged wood exposed, posing a risk to residents, especially those in wheelchairs. Other observations included a protruding metal cover with sharp edges, stained floors, and exposed screws in the corridors. Interviews with facility staff, including a CNA, DON, and Maintenance Director, revealed that residents had complained about the cleanliness and condition of the facility. The staff acknowledged the need for environmental improvements, with some staff members donating their time for basic updates. However, the Maintenance Director indicated that additional help was needed to address the building's condition. The facility's policy on providing a homelike environment emphasized the importance of maintaining a clean, sanitary, and orderly environment, which was not being met according to the observations and staff reports.
Resident Denied Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident had ready and reasonable access to her personal funds, which resulted in the resident experiencing anxiety and frustration. The resident, who was moderately cognitively impaired and had a history of myocardial infarction, hypertension, and chronic obstructive pulmonary disease, was unable to access $80 from her facility-managed trust account. This money was needed to pay important bills, including insurance on her house and life insurance. The resident had a routine of withdrawing money to give to her son for bill payments, but her request was denied due to the facility's concern about not having enough cash on hand for other residents. Interviews with facility staff revealed that the facility was experiencing difficulties in maintaining an adequate amount of cash for resident withdrawals due to the absence of a full-time Business Office Manager. The Regional Business Office Manager visited the facility once a week to manage the resident trust account, but discouraged withdrawals over $50. The receptionist, who managed day-to-day withdrawals, confirmed the limited cash availability and stated that the resident had not received the full amount requested. The facility's Trust Fund Policy indicated that withdrawals should be made available within three working days, but this was not adhered to in the resident's case.
Misappropriation of Resident's Money Due to Inadequate Safeguards
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's money, resulting in the loss of a lock box containing $152. This incident involved a resident who was admitted to the facility and had a care plan that included the provision of a lock box to keep personal money safe. Despite this measure, the lock box went missing, and the facility's investigation, along with the local police department, was unable to identify a suspect. The resident reported seeing the lock box about two weeks prior to the incident and expressed concerns about the security of her money. The resident experienced feelings of frustration, helplessness, and a lack of trust in the facility's staff following the theft. She reported frequent worry about her money and other belongings, which affected her sleep and led her to refuse to get out of bed to ensure her belongings were safe. Interviews with staff indicated that the resident appeared easily frustrated and that maintaining control over her money was important to her. The Director of Nursing confirmed that the police investigation did not yield a suspect, highlighting the facility's failure to safeguard the resident's property effectively.
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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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