Resthaven Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holland, Michigan.
- Location
- 280 W 40th St, Holland, Michigan 49423
- CMS Provider Number
- 235378
- Inspections on file
- 19
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Resthaven Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
The facility did not provide quarterly financial statements for resident trust accounts to any of the eight residents using these accounts. Instead, statements were only given annually or upon request, and staff confirmed that quarterly statements were not routinely distributed. This resulted in residents not being systematically informed about their personal funds.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that a resident received treatment and supports for daily living in a safe manner. The report does not include further details about the specific circumstances or individuals involved.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was upheld.
A resident with severe cognitive impairment and an appointed guardian was admitted without a documented code status order for several days. Although the resident's wish to be DNR was known, staff interviews and record review confirmed that no physician order for code status was present until after the deficiency was identified, contrary to facility policy requiring code status documentation at admission.
A resident with mental health diagnoses did not have a required annual PASARR Level I Screening Form completed, as review of records showed the most recent form was from the previous year. Staff interviews confirmed the form was not completed or could not be located, resulting in a deficiency in required documentation.
A resident with dementia and fragile skin was observed with a bandage on her forearm that lacked required date and initials, and without the protective derma sleeves specified in her care plan. Documentation indicated derma sleeves were in use, but this was not observed. There was also no physician order for the dressing applied to the skin tear. Nursing staff confirmed the bandage should have been properly labeled, and the wound nurse was not involved in the care. These actions did not meet professional nursing standards.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Two residents with cognitive impairment and mobility issues were not provided with adequate supervision or safe transfer techniques, resulting in increased risk for falls and injuries. Staff failed to use gait belts during transfers and did not consistently respond to or hear alarms, leading to multiple unwitnessed falls and incidents where residents attempted to self-transfer without assistance.
A resident with severe cognitive impairment and multiple medical conditions, including Barrett's esophagus and diabetes, did not consistently receive meals in accordance with their documented food preferences and dislikes. Despite repeated notifications from the resident's DPOA about the need to avoid spicy foods due to gastrointestinal discomfort, staff continued to serve such items. Dietary staff were unaware of the full scope of the resident's preferences, and meal tickets did not accurately reflect necessary dietary restrictions, leading to ongoing dissatisfaction and potential health concerns.
A resident with Type 1 diabetes required frequent blood glucose monitoring. An LPN failed to clean and disinfect a glucometer after use, placing it back into the medication cart without sanitizing it, which led to potential contamination of other items. Staff interviews and facility policy confirmed that the glucometer should have been cleaned after each use.
The facility failed to maintain sanitary conditions in the kitchen, including improper temperature logging, thawing meat inappropriately, unclean utensils, and improper food storage and labeling. These violations pose a risk of foodborne illness to residents.
The facility failed to properly clean and sanitize shared equipment, ensure PPE was worn by staff and visitors in required areas, and maintain clean laundry bins. Additionally, a resident did not have a dressing applied to their dialysis access site as required.
The facility failed to provide a written notice of transfer for a resident hospitalized for severe abdominal issues, and did not notify the Ombudsman of emergency transfers. Interviews revealed inconsistencies in the notification process, leaving residents and their representatives uninformed and without advocacy support.
The facility failed to provide written notification of the bed hold policy upon transfer to the hospital for a resident with a history of benign prostatic hyperplasia and obstructive uropathy. Despite staff claims of notifying the resident or representative, there was no documentation to confirm this communication, violating the facility's policy.
The facility failed to follow physician orders and implement correct precautions for two residents, leading to a lack of documentation and potential delays in treatment. One resident did not have a daily dressing change for a dialysis port, and another was incorrectly placed on droplet precautions instead of enhanced barrier precautions.
The facility failed to follow orders for monitoring blood sugars for a resident and to follow orders for dressing changes for another resident, resulting in the lack of monitoring and the resident not receiving appropriate interventions. The deficiencies were due to missing schedules in order entries and improper dressing change procedures.
The facility failed to ensure services to maintain and prevent further decrease in ROM for a resident with cerebral palsy, resulting in potential for decreased ROM, contractures, and pain. The resident reported not receiving the prescribed therapy, and observations confirmed that CNAs were not performing the necessary PROM exercises as outlined in the care plan.
The facility failed to ensure physician orders and proper monitoring for two residents requiring dialysis care. Both residents lacked detailed care plans and consistent documentation, and staff were unaware of the dialysis details and monitoring requirements, leading to potential risks for the residents' well-being.
The facility failed to post required nurse staffing information daily for all 135 residents, resulting in a lack of available staffing information for residents and visitors. Observations revealed no postings, and interviews with the DON and NHA indicated they were unaware of the requirement. The scheduler responsible for this task had not been working for approximately 8 weeks.
The facility failed to respond to call lights timely for two residents, leading to feelings of neglect and increased anxiety. One resident with multiple diagnoses, including an above-knee amputation, was left unattended after a bowel movement, while another resident with cerebral palsy experienced increased anxiety due to delayed responses. Staff interviews revealed issues with the call light system, and call light reports confirmed multiple instances of delays.
A resident with multiple diagnoses, including cerebral palsy and osteoporosis, fell and sustained minor injuries during a Hoyer lift transfer when the loop came off the hook. The care plan did not indicate the need for a Hoyer lift, and staff were educated on ensuring loops are securely attached before raising residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly financial statements for resident trust accounts to all 8 residents who utilized these accounts. According to interviews and record review, the Accounting Associate reported that financial statements were only provided annually and upon request, and was unaware of any quarterly distribution. The Resident Services Coordinator also confirmed that quarterly statements were not provided, although residents could inquire about their balances at any time. The Nursing Home Administrator acknowledged that the facility did not currently provide quarterly trust fund financial statements, but could issue them upon request. As a result, residents were not systematically informed about the status of their personal funds as required.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Document Advance Directive Code Status on Admission
Penalty
Summary
The facility failed to ensure accurate and timely documentation of advance directives, specifically code status, for one resident upon admission. The resident, who had vascular dementia and Alzheimer's disease and was severely cognitively impaired, was admitted without an order or documentation regarding her code status for the first five days of her stay. Although the resident expressed a wish to be Do Not Resuscitate (DNR), she had an appointed guardian and was unable to make medical decisions herself. Interviews with facility staff revealed that the admitting nurse was responsible for completing advance directive forms and entering code status orders, and that a physician order was required for code status. However, review of the resident's record confirmed that no such order was present during the initial days of admission. Staff interviews further indicated that, according to facility policy, a resident is considered full code until a DNR form is signed by both the resident or their representative and the physician. The absence of a code status order was confirmed by multiple staff members, and the order for full code was only added after the deficiency was identified. The facility's policy required that code status be established and documented as part of the admission process, but this was not followed in the case of this resident, resulting in a lack of clear documentation regarding life-sustaining interventions during a critical period.
Failure to Complete Annual PASARR Level I Screening
Penalty
Summary
The facility failed to ensure that a required annual Preadmission Screening and Resident Review (PASARR) Level I Screening Form (DCH-3877) was completed for a resident with mental health diagnoses, including anxiety disorder, dementia with psychotic disturbance, and delusional disorders. The resident was found to be cognitively intact, as indicated by a BIMS score of 13 out of 15 on a recent MDS assessment. Documentation review revealed that the most recent Level I PASARR form in the resident's record was completed in November of the previous year, with no subsequent annual form found in the electronic medical record. Interviews with facility staff confirmed that the annual PASARR Level I form had not been completed as required. The Social Services Technician acknowledged the oversight, and the responsible Social Worker indicated that the form was marked as completed in their system but could not be located. Further inquiry with the OBRA coordinator also failed to produce a more recent Level I form, confirming the deficiency in maintaining up-to-date PASARR documentation for the resident.
Failure to Follow Professional Standards in Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that professional standards of nursing were followed in the treatment of a skin tear for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and pressure-induced deep tissue damage, was care planned for potential skin integrity impairment due to limited mobility and incontinence, with interventions such as derma sleeves for arm protection. However, during multiple observations, the resident was seen with a bandage on her left forearm that lacked a date and initials, and no derma sleeves were present on her arms as required by her care plan. Review of records showed documentation of derma sleeves on the Treatment Administration Record, but this was not consistent with direct observation. Additionally, there was no physician order for a dressing for the resident's left forearm skin tear, despite the presence of a bandage. Interviews with nursing staff confirmed that the bandage should have been dated and initialed, and that the wound nurse was not involved unless the skin tear was significant. The Director of Nursing acknowledged the resident's fragile skin and the need for protective interventions, but these were not observed in practice. These findings indicate a failure to follow professional standards and care plan interventions for skin integrity and wound care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Failure to Provide Adequate Supervision and Safe Transfer Techniques
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate transfer techniques for two residents, resulting in increased risk for falls and injuries. One resident with severe cognitive impairment and dementia required supervision or light assistance for transfers. During an observation, two CNAs assisted this resident from a low recliner by placing their forearms under her armpits and lifting her without the use of a gait belt, contrary to facility policy and expectations. Both the physical therapist and nursing home administrator confirmed that a gait belt should always be used for such transfers to ensure safety and prevent injury. Another resident with dementia, Parkinson's disease, and a history of falls experienced multiple unwitnessed falls and incidents of attempting to self-transfer. Documentation revealed repeated episodes where the resident was found on the floor or attempting to get up from a recliner without adequate staff supervision. Alarms intended to alert staff to the resident's movements were not always functional or audible in all areas, and staff were not consistently present or able to respond promptly. Interviews with staff and family members indicated lapses in supervision, with staff sometimes unavailable or not carrying necessary alert devices, and family expressing concerns about the lack of staff presence and responsiveness. Facility policies required the use of gait belts for transfers and outlined interventions for fall prevention, including increased supervision and use of alarms. However, observations and record reviews demonstrated that these policies were not consistently followed. The lack of proper transfer technique and insufficient supervision contributed to repeated falls and near-miss incidents, highlighting failures in implementing established safety protocols for residents at risk of accidents.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure that a resident received food items in accordance with their documented preferences, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset. The resident in question had a history of vascular dementia, Barrett's esophagus with dysplasia, diabetes mellitus, and dysphagia, and was severely cognitively impaired. The care plan and Kardex indicated specific food preferences, including a dislike for spicy foods and mac n cheese, and a preference for seafood and tomato juice at meals. Despite these documented preferences, the resident continued to receive spicy foods, which the resident's Durable Power of Attorney (DPOA) reported caused heartburn and gastrointestinal discomfort. The DPOA had repeatedly informed staff of these preferences, but the issue persisted, and the resident was observed to reject spicy food items such as potato wedges. Interviews with dietary staff revealed a lack of awareness and communication regarding the resident's food preferences. The dietary aide responsible for meal preparation stated that she was only aware of the restriction on tomato juice and was not informed of other preferences or dislikes. The Registered Dietician (RD) confirmed that food preferences were recorded at admission and updated as needed, but relied on floor staff or the interdisciplinary team to communicate any changes. The RD was not aware of the DPOA's concerns and did not routinely reach out to family members unless there were significant nutritional issues, such as weight loss or ongoing gastrointestinal upset. The meal tickets for the resident did not reflect the documented dislikes or the need to avoid spicy foods. Facility policy required dietary staff to obtain food preferences, allergies, or intolerances within 72 hours of admission and to update this information as needed. However, the process for updating and communicating these preferences was not effectively implemented, resulting in the resident receiving meals that did not align with their documented needs and preferences. This failure was confirmed through observation, interviews, and record review.
Failure to Sanitize Glucometer Between Resident Uses
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to properly sanitize a glucometer after checking the blood sugar of a female resident with Type 1 diabetes. The resident required blood glucose monitoring before every meal and at bedtime. After performing a blood sugar check, the LPN placed the used glucometer into a drawer of the medication cart without cleaning or disinfecting it, contrary to facility policy and manufacturer instructions. The glucometer came into contact with other items in the drawer, potentially contaminating them. Interviews with multiple LPNs and the Education and Infection Control Nurse confirmed that the expectation was for the glucometer to be cleaned after each use and before storage. The facility's policy also required cleaning and disinfection of the glucometer between residents. The LPN acknowledged the failure to clean the device and recognized that the items in the drawer were now contaminated as a result.
Sanitary Violations in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential foodborne illness risks for residents. During an initial tour, it was observed that the Blueair Refrigeration unit had an external digital thermometer reading 34F, but the internal temperature of an open half-gallon of milk was 55F. The Kitchen Supervisor admitted that the temperature logged earlier was based on the external thermometer, and all food in the unit was discarded. Additionally, eight packages of beef roasts were found thawing in the wash compartment of a three-compartment sink, which is against FDA guidelines as it can lead to contamination of equipment and utensils. The drain line from the wash compartment was directly connected to the wastewater line, further increasing the risk of contamination. The inspection also revealed several instances of unclean equipment and surfaces. A green mechanical scoop with stuck-on food debris was stored with clean utensils, and juice dispensers had dried sticky debris on the underside of the spouts. In the Borsma Cottage kitchen, the resident silverware drawer contained food crumbs and debris, and some utensil drawers were pitting and chipping, making them difficult to clean. These conditions violate FDA guidelines that require food-contact surfaces and utensils to be clean to sight and touch. Further observations found issues with the storage and labeling of food items. In Rachel's Kitchen, a container of shake supplements had smeared writing and illegible discard dates, with some past their discard date. Thickened water and juice containers were not dated for discard once opened, and a package of sliced ham had a smeared date. In the [NAME] kitchen area, shell eggs were stored above ready-to-eat products, risking cross-contamination. These practices violate FDA guidelines for date marking and separation of raw and ready-to-eat foods, posing a significant risk to resident safety.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure resident shared equipment was properly cleaned and sanitized between each use. During an observation, an LPN was noted taking vitals on multiple residents without cleaning and sanitizing the vitals machine between uses. The LPN acknowledged that the vitals machine should have been cleaned and sanitized between each use to prevent the spread of infection. The Infection Control Nurse confirmed that resident shared equipment should be cleaned and sanitized between every resident every time to prevent the spread of infection. The facility also failed to ensure that personal protective equipment (PPE) was worn by staff and visitors in care units where required. Despite clear signage indicating the need for masks due to a respiratory infection outbreak, visitors and staff were observed not wearing masks in the affected areas. Staff members, including a Clinical Manager and an LPN, did not direct visitors to don surgical masks, even after being queried about the requirement. The Infection Control Nurse reiterated that all staff and visitors were expected to wear surgical masks in the affected units to prevent the spread of the virus. Additionally, the facility failed to ensure clean laundry bins used for transport were free from dirt and debris. During a tour of the laundry room, it was observed that clean laundry bins contained debris, including socks, paper trash, rubber bands, and an accumulation of dirt and crumbs. Furthermore, the facility did not ensure that a resident sampled for dialysis had a dressing applied to their dialysis access site. The resident's medical records indicated a daily dressing change order, but this order was not reflected in the Medication Administration Record/Treatment Administration Record, and the resident was observed without a dressing on the dialysis port, which had small openings that were scabbed over.
Failure to Provide Written Notice of Transfer and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Specifically, Resident #98, who had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and a suprapubic catheter, was sent to a local hospital for severe abdominal distention, pain, and fever. The family was notified, but there was no documentation that a written notice of transfer was provided to the resident or their representative. Additionally, the local Ombudsman had not received transfer notices since 2022, indicating a systemic issue with notification procedures. Interviews with facility staff, including an LPN, Clinical Manager, Social Worker, and Director of Nursing, revealed inconsistencies and gaps in the transfer notification process. The LPN reported that a packet, including bed hold information, was sent with the ambulance service, but there was no confirmation that the resident or representative received a written notice. The Clinical Manager and Social Worker were unsure if the necessary forms were sent, and the Director of Nursing admitted there was no documentation in the medical record confirming communication about the bed hold. This lack of proper notification and documentation left residents and their representatives uninformed and without advocacy support from the Ombudsman.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy upon transfer to the hospital for a resident, resulting in the potential for residents and/or their representatives to be unaware of their rights regarding facility bed holds. The deficiency was identified during the review of Resident #98's records and interviews with staff. Resident #98, who had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and a suprapubic catheter, was transferred to a local hospital for severe abdominal distention, pain, and fever. Despite the transfer, there was no documentation in the medical record indicating that the resident or their representative had been provided with written notice of the bed hold policy as required by the facility's policy. Interviews with various staff members, including LPNs, Clinical Managers, and the Director of Nursing, revealed inconsistencies in the process of notifying residents or their representatives about the bed hold policy. While some staff mentioned that a packet including the bed hold information was handed to the ambulance service, others stated that the admissions coordinator would contact the resident or representative to discuss the bed hold. However, there was no documentation to confirm that these communications had occurred. The facility's policy required that written notice of the bed hold policy be provided upon transfer and that all attempts to reach the resident's representative be documented, which was not adhered to in this case.
Failure to Follow Physician Orders and Implement Correct Precautions
Penalty
Summary
The facility failed to ensure professional standards of practice for physician orders were obtained and followed for two residents, resulting in a lack of documentation and potential delays in treatment. For Resident 91, who required a fistula/port for dialysis due to chronic kidney disease stage V, the order to change the dressing at the hemodialysis site daily was not included in the Medication Administration Record/Treatment Administration Record (MAR/TAR) from February 23, 2023, through June 5, 2024. This oversight was confirmed by both a Licensed Practical Nurse (LPN) and the Clinical Manager, who acknowledged that the order was missed during the routine checks and double-checks of the resident's care plan and orders. An observation revealed that the resident's dialysis port had no dressing and had three small scabbed-over openings, indicating a lack of proper care and documentation. For Resident 291, who had multiple diagnoses including lung cancer, heart failure, pneumonia, asthma, sepsis, MRSA, diabetes, muscle wasting, and low back pain, the facility failed to properly document and implement the correct precautions. Although the resident was placed on droplet precautions with full personal protective equipment (PPE) upon admission, there was no corresponding order in the medical record. The Infection Control Nurse (ICN) and Director of Nursing (DON) confirmed that the order checks were improperly completed by the same nurse on the same day, and the resident should have been placed on enhanced barrier precautions (EBP) instead. The ICN noted that the staff was confused about implementing EBP, leading to the incorrect application of droplet precautions. The Director of Nursing explained that the admission paperwork process involved multiple checks by different staff members, but in this case, the necessary precautions were not correctly documented or communicated. The failure to accurately document and follow physician orders for both residents highlights significant lapses in the facility's adherence to professional standards of care, resulting in potential risks to the residents' health and safety.
Failure to Follow Physician Orders for Blood Sugar Monitoring and Dressing Changes
Penalty
Summary
The facility failed to follow orders for monitoring blood sugars for one resident and to follow orders for dressing changes for another resident, resulting in the lack of monitoring and the resident not receiving appropriate interventions. For Resident #292, the facility did not perform the required blood sugar checks before breakfast and dinner for five days as ordered. The order was entered without a routine or schedule, which prevented it from transferring to the medication administration record (MAR), leading to the omission of blood sugar monitoring. Interviews with the LPN, Clinical Manager, and Director of Nursing confirmed that the order was not properly checked and did not prompt the nurses to complete the blood sugar checks due to the missing schedule in the order entry system. For Resident #119, the facility did not follow the prescribed procedure for changing the dressing on a wound on the resident's head. The LPN did not allow the wound to drain for 10 minutes before applying a new bandage and did not use the specified coban wrap. Additionally, the LPN did not wear a gown during the dressing change. Interviews with the LPN, RN, and DON revealed that the proper procedure was not followed, and the wound dressing change was not performed according to the physician's order. The DON also noted that the resident's spouse was permitted to change the dressing using hospice supplies, but there was no current order to support this practice. These deficiencies highlight a lack of adherence to physician orders and proper procedures, resulting in potential risks to the residents' health. The failure to monitor blood sugars and perform dressing changes as ordered could lead to worsening health conditions for the affected residents.
Failure to Maintain Range of Motion for Resident
Penalty
Summary
The facility failed to ensure services to maintain and prevent further decrease in range of motion (ROM) for a resident with cerebral palsy, resulting in the potential for decreased ROM, contractures, and pain. The resident, who was cognitively intact, reported increasing pain and cramps in her legs and stated that she was not receiving the prescribed therapy for her arms and legs. Observations and interviews revealed that the CNAs were not performing the prescribed passive ROM (PROM) exercises as outlined in the resident's care plan. Instead, they considered dressing the resident as fulfilling the ROM requirement, which did not involve the necessary repetitions of bending the arms and legs. Interviews with the clinical manager and CNA manager confirmed that the CNAs were expected to perform PROM exercises per the care plan, but this was not being done correctly. Documentation over the past 30 days showed inconsistent performance of PROM exercises, with the resident tolerating them well only 12 out of 30 days. The facility's policy on ROM exercises emphasized the need for gentle, smooth, and repetitive movements to maintain function and prevent decline, which was not being adhered to in this case.
Failure to Ensure Proper Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure physician orders were in place for dialysis treatment and monitoring, and post-dialysis assessments were documented for two residents requiring dialysis care. Resident #65, who was admitted with stage 4 chronic kidney disease, reported not seeing any facility staff after returning from dialysis and was unsure who was responsible for changing the dressing on his dialysis port. The care plan for Resident #65 did not specify the type of dialysis, the schedule, or monitoring requirements, and there were no physician orders or treatment records for dialysis in his file. Additionally, vital signs were not consistently recorded, particularly on dialysis days, and the facility staff were unaware of the dialysis details and monitoring requirements for Resident #65's port site. Resident #91, who required dialysis for chronic kidney disease stage V, also lacked physician orders for dialysis, including the schedule and designated dialysis facility. The care plan for Resident #91 mentioned the need for dialysis three times a week but did not specify the days or the dialysis facility. During an interview, Resident #91 confirmed his dialysis schedule, but the Clinical Manager could not find any orders for dialysis in his records. The facility's policy on dialysis care, which includes detailed requirements for physician orders and monitoring, was not followed for both residents. The facility's failure to adhere to its dialysis care policy resulted in a lack of proper documentation and monitoring for both residents. This included missing physician orders, incomplete care plans, and inconsistent recording of vital signs. The staff interviews revealed a lack of awareness and understanding of the residents' dialysis needs and the necessary monitoring protocols, leading to potential risks for the residents' well-being.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information on a daily basis for all 135 residents, resulting in a lack of available staffing information for residents and visitors. During multiple observations on 06/04/24 and 06/05/24, no postings indicating the daily nurse staffing hours were found throughout the facility halls and common areas. In interviews, both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported that they were unaware of the requirement to post nurse staffing hours. The DON further mentioned that the responsibility for posting the daily nurse staffing hours was assigned to the scheduler, who had not been working in the facility for approximately 8 weeks.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to provide an environment that promoted a dignified experience and respond to resident call lights timely for two residents, resulting in feelings of humiliation, embarrassment, and concern about receiving timely assistance in the event of a medical emergency. Resident #100, a male with multiple diagnoses including muscle wasting, dementia, and an above-knee amputation, reported feeling neglected and disrespected by the staff. He recounted an incident where he had a loose bowel movement and was left unattended for an extended period, causing him significant distress. Call light reports confirmed multiple instances where his call light was on for 30 minutes or more. Resident #103, a female with cerebral palsy and other conditions, also experienced delays in call light responses, which increased her anxiety and worry. She expressed that staff could have communicated better by informing her they would be there soon. Call light reports for her also showed multiple occasions where the call light was on for over 30 minutes. Interviews with staff revealed issues with the call light system, including phones being turned down or off, and a lack of consistent monitoring of call light alerts. The facility's policy stated that call lights should be answered within 7 to 15 minutes, but this was not consistently followed. The failure to respond to call lights in a timely manner negatively impacted the residents' quality of life and sense of dignity.
Failure to Ensure Resident Safety During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure resident safety during a Hoyer lift transfer, resulting in a fall with minor injury for Resident #103. Resident #103, who has diagnoses including cerebral palsy, pain, anxiety, embolism, abnormal posture, anemia, and osteoporosis, was being transferred from her wheelchair to her bed when the incident occurred. The care plan for Resident #103 did not indicate the need for a Hoyer lift for transfers, and the Minimum Data Set (MDS) indicated that the resident was dependent on helpers for transfers. During the transfer, the Hoyer loop came off the hook, causing the resident to fall and hit her head, resulting in a lump on the back of her head and an abrasion on her back. The incident was reported by the resident's spouse and documented in the facility's records, including an Incident/Accident/Unusual Occurrence Progress Note and an Incident Report. Interviews with staff members revealed that two CNAs were assisting with the transfer when the loop slipped off, and the resident fell to the floor. The CNAs were educated on ensuring the loops were securely attached before raising the resident. The facility's policy on safe handling and transfers requires two staff members for full-body lifts and adherence to the manufacturer's instructions for using the mechanical lift. The procedure for transferring clients with a mechanical lift includes steps to ensure the resident's safety, such as checking that all hooks remain secure and raising the resident only a few inches above the chair before moving them to the bed. However, in this case, the failure to properly secure the Hoyer loop led to the resident's fall and injury.
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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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