Riverside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Louis, Michigan.
- Location
- 1149 West Monroe Road, St. Louis, Michigan 48880
- CMS Provider Number
- 235324
- Inspections on file
- 22
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Riverside Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and incontinence did not receive care planned interventions or physician-ordered Calmoseptine ointment for pressure ulcer prevention. Staff failed to check and change the resident every two hours as required, and there was confusion among CNAs and nurses regarding responsibility for applying the ointment. Documentation indicated the ointment was administered when it was not, and staff were unaware of the specific order to apply it after each incontinence episode.
The facility failed to maintain cleanliness in food service equipment, affecting 38 residents. Observations revealed unclean conditions, including soiled pots, pans, and kitchen appliances. The Dietary Manager acknowledged the issues and missing cleaning records.
The facility failed to maintain accurate advanced directive information for two residents, leading to potential non-compliance with their medical care preferences. One resident's directive was improperly witnessed after the guardian and doctor signed, while another resident's directive was signed by witnesses a day after the resident, indicating they did not witness the signing. These procedural errors could result in the facility not following the residents' medical care preferences.
The facility failed to provide timely and accurate Medicare coverage notices to three residents. A resident was not informed of the end date of services, and two residents did not receive proper notification 48 hours prior to the end of skilled services. Additionally, the SNFABNs lacked necessary details such as reasons for non-coverage and estimated costs. The Business Office Manager confirmed these deficiencies but could not explain the omissions.
A facility failed to include a Foley catheter in a resident's Baseline Care Plan within 48 hours of admission, despite the resident having quadriplegia and an indwelling urinary catheter. Observations confirmed the presence of the catheter, but it was not documented in the initial care plan, and interventions were only created weeks later. Staff acknowledged the omission during interviews.
A resident with severe cognitive impairment and a history of constipation experienced ongoing issues with constipation that were not adequately addressed by the facility. Despite having multiple physician's orders for constipation management, some orders lacked specific dosing and route instructions. The resident did not have a recorded bowel movement for several days, and no as-needed medications were administered, indicating a failure in the facility's protocol to manage the resident's condition effectively.
The facility failed to ensure a safe environment for two residents regarding smoking and bedrail use. A resident was allowed to smoke independently without a completed risk assessment, posing a safety risk. Another resident had a bedrail without a physician's order or care plan, and no assessments or measurements for entrapment were conducted, indicating a lack of proper safety procedures.
A facility failed to ensure recommended laboratory monitoring for a diabetic resident, who was on insulin and Metformin. Despite a pharmacy review recommending A1C and Lipid Panel tests, and the physician's agreement, the resident refused the tests in June. By October, the resident's lab results still lacked an A1C test. An RN confirmed the absence of A1C results since February, highlighting a failure in monitoring the resident's drug regimen.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An RN did not wash her hands before preparing medications and failed to administer Lexapro and Betamethasone as ordered. The RN left medications unattended at the bedside, and the medication administration record confirmed the omissions. Interviews indicated that nurses are expected to wash hands and not leave medications at the bedside.
A facility failed to follow infection control protocols during wound care for a resident with Alzheimer's and pressure ulcers, as a nurse did not change gloves or clean scissors between handling soiled and new dressings. Additionally, the facility did not obtain proper consent for a COVID-19 immunization for a resident with Huntington's disease, as the guardian signed the declination section of the consent form, and verbal consent was not documented.
The facility did not post daily nurse staffing information for 38 residents and visitors. During facility tours, the postings were not observed, and HR reported that the information had not been completed or posted for about two months, believing it was no longer required.
The facility did not provide documentation of the required bi-annual Sensitivity Test for its fire alarm system, as required by NFPA 70 and NFPA 72. This was confirmed during a record review and interview with Facility Maintenance.
The facility did not provide a smoke barrier map showing complete compartmentalization by smoke barriers throughout the building, as required by code. The map lacked details of smoke barriers separating compartments from outside wall to outside wall, and this was confirmed by Facility Maintenance during record review.
Surveyors found that more than 100 cigarette butts were discarded on the ground in shrubbery and leaves in front of all emergency exits, rather than being placed in noncombustible containers as required by smoking regulations. This was confirmed by Facility Maintenance during the inspection.
A hasp latching mechanism with a padlock was found on the kitchen storage cooler door, allowing it to be locked from the outside and preventing egress from within. This arrangement did not meet required standards for egress doors and was confirmed by Facility Maintenance during the survey.
Staff were unable to provide access to a supply storage room in the service hall, preventing surveyors from verifying that the hazardous area was properly protected by required fire barriers or an automatic extinguishing system. This deficiency was confirmed by Facility Maintenance and could affect 20 occupants in a fire emergency.
A smoke detector was found installed within three feet of direct airflow from an air return or supply near an exit door, contrary to NFPA 70 and NFPA 72 requirements. This installation issue was confirmed by Facility Maintenance and could impact 30 occupants during a fire emergency.
A gap was found in the med supply room door handle, preventing the door from effectively resisting the passage of smoke as required by NFPA standards. This deficiency was confirmed by maintenance staff and could impact the safety of up to 20 occupants during a fire emergency.
A receptacle box with exposed live electric wires was found hanging off the wall behind the kitchen garbage disposal, creating a risk of unintentional electrical exposure. This noncompliance with NFPA 70 was confirmed by Facility Maintenance during the survey.
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas. Staff were seen stepping on and killing the insects, but no formal pest control measures were observed. Additionally, the dining room was found to be unsanitary, with soiled tables and overflowing trashcans. Two residents, both moderately cognitively impaired, reported dissatisfaction with the cleanliness and presence of insects.
The facility failed to follow professional standards of nursing practice for medication administration, resulting in multiple medication errors and mismanagement of controlled substances for four residents. Issues included administering medication despite contraindicated vital signs, failing to document controlled substances properly, and not notifying providers of missed doses.
The facility failed to secure smoking materials per protocol. An observation revealed an open closet door in the shower room containing a plastic box with 7 packs of cigarettes and 2 lighters. Although the box had a padlock, it was not secured. The Administrator confirmed that smoking materials were supposed to be double locked but were not.
Failure to Implement Care Plan and Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified regarding the facility's failure to implement care planned interventions and physician-ordered treatments for pressure ulcer prevention for one resident. The resident in question was admitted with diagnoses including cerebral infarction and hemiplegia, was severely cognitively impaired, and was dependent on staff for toileting and personal hygiene. The care plan directed staff to keep the resident's skin clean and dry, minimize exposure to moisture, provide incontinence care after each episode, and use a moisture barrier product as needed. There was also a physician's order for Calmoseptine ointment to be applied to the buttocks after each episode of incontinence. Observations on two consecutive days revealed that the resident was left in a soaked brief and clothing for several hours after being placed in a chair by the previous shift. During incontinence care, there was no evidence of barrier cream or Calmoseptine ointment on the resident's skin, and staff did not apply these products at the time of care. Interviews with CNAs indicated that the resident had not been checked or changed for several hours, despite the expectation that incontinent residents be checked and changed every two hours. CNAs also expressed confusion about who was responsible for applying Calmoseptine ointment, with some believing it was a nursing responsibility and others stating they would apply it only if it was available in the room. Further interviews with nursing staff and the Director of Nursing confirmed that Calmoseptine ointment was considered medicated, stored in the treatment cart, and should be administered by a nurse. Documentation in the Medication Administration Record indicated that the ointment had been administered, but the nurse later admitted this was not the case and that CNAs typically performed this task. There was also a lack of awareness among staff regarding the specific order for Calmoseptine ointment to be applied after each incontinence episode. These findings demonstrate a failure to follow care plan interventions and physician orders for pressure ulcer prevention.
Deficient Cleaning and Maintenance of Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 38 residents. During an initial tour of the food services, several deficiencies were observed. A cardboard box containing dinex cup lids was found on the floor in the dry storage room, and the baseboards along the wall had a black substance on them. The door jam of the dry storage room was rusted along the floor. In the freezer, referred to as the vegetable freezer, the bottom shelf was soiled with what appeared to be a dried liquid film. Additionally, seven pots and pans were found with a dark-colored substance inside, resembling baked-on food that could not be removed. Further observations revealed that the toaster grill had baked-on substances and burnt toast crumbs on the grates. The grill, oven, and gas grills were soiled, with the upper portion of the grill covered in a dark black substance. The oven door handle was greasy, and the oven racks were discolored with food substances. The bottom of the oven was covered with burnt grease and food substances, and the side of the oven door had old yellow dark grease. During an interview, the Dietary Manager acknowledged the unclean state of the equipment and noted that cleaning records were missing for two days prior to the inspection.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure updated and accurate advanced directive information was in place for two residents, resulting in the potential for a resident's preferences for medical care to not be followed. Resident #7, who was cognitively intact, had an advanced directive signed by a guardian on 09/24/24, but the witnessing process was not correctly followed. The social worker signed the document after the guardian and doctor, contrary to the instructions that required witnessing the guardian or resident's signature at the time of signing. This discrepancy was due to the social worker following incorrect procedures taught to her when she started working at the facility. Resident #39, who was cognitively impaired, signed his advanced directive on 01/28/25, with the provider also signing on the same day. However, the witnesses signed the document on the following day, 01/29/25, which means they did not witness the resident's signature as required. This procedural error in handling advanced directives could lead to the facility not adhering to the residents' medical care preferences.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide accurate and timely notifications regarding Medicare coverage and potential liability for services not covered to three residents. Resident #5 was not given a Notice of Medicare Non-Coverage (NOMNC) indicating when services would end, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) did not specify the last covered day of services. Resident #8 was not notified 48 hours prior to the end of skilled services, and the SNFABN did not include the estimated cost of services. Resident #35's NOMNC did not indicate when services would end, and the SNFABN lacked the reason for non-coverage and estimated costs. The Business Office Manager (BOM) confirmed these deficiencies during an interview, acknowledging the failure to provide necessary information on the NOMNC and SNFABN forms. The BOM could not explain why the required information was missing or why notifications were not completed in a timely manner. These oversights affected the residents' understanding of their Medicare coverage and potential financial responsibilities.
Failure to Include Foley Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a Baseline Care Plan with necessary healthcare information for a resident (R37) within 48 hours of admission. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had an indwelling urinary catheter. However, the Baseline Care Plan initiated on the date of admission did not reflect the presence of the Foley catheter, which is a critical component of the resident's care needs. Observations and interviews revealed that the resident was cognitively intact and had a Foley catheter, as confirmed by the resident and observed by surveyors. Despite this, the Baseline Care Plan did not include the catheter, and the approaches/interventions related to the catheter were only created weeks after admission. Staff interviews indicated that the Care Plan is used to identify resident care needs, and the omission of the catheter from the Baseline Care Plan was acknowledged by the Nursing Home Administrator/Director of Nursing.
Failure to Prevent Constipation and Ensure Proper Medication Orders
Penalty
Summary
The facility failed to prevent constipation and ensure proper medication orders for a resident with severe cognitive impairment and a history of constipation, diabetes, and hemiplegia. The resident reported ongoing issues with constipation since admission, which they felt were not adequately addressed by the staff. The medical record showed multiple physician's orders for constipation management, including Metamucil, Senna Plus, and other medications, but some orders lacked specific dosing and route instructions. Observations and interviews revealed that the resident did not have a recorded bowel movement for several consecutive days, and the Medication Administration Record did not reflect the administration of any as-needed medications for constipation. A registered nurse acknowledged the lack of bowel movements over a significant period and the absence of action to address the issue, indicating a failure in the facility's protocol to manage the resident's constipation effectively.
Failure to Ensure Safety in Smoking and Bedrail Use
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision for two residents regarding smoking and the use of bedrails. Resident #2 was observed to have burn marks on his hoodie and stated he could smoke independently, yet there was no completed smoking risk assessment on file since his admission. This lack of assessment and supervision poses a potential safety risk, as the resident mentioned having access to a lighter and marijuana outside, which was not addressed by the facility. Resident #5 was found to have a bedrail on the right side of his bed without a physician's order or a care plan in place. The resident explained that the bedrail was used to prevent falls, but there was no documentation of an assessment for its use, nor were any alternative interventions attempted. Additionally, the facility did not conduct measurements for possible entrapment when the bedrail was applied or on a quarterly basis, as confirmed by the Director of Nursing. This oversight indicates a failure to follow proper procedures for bedrail use and safety assessments.
Failure to Ensure Laboratory Monitoring for Diabetic Resident
Penalty
Summary
The facility failed to ensure that recommended laboratory monitoring was in place for a resident, identified as R15, who was admitted with diagnoses including diabetes, constipation, hemiplegia, and hemiparesis following a nontraumatic intracranial hemorrhage. R15's medical record included physician's orders for insulin and Metformin to manage diabetes, with instructions for fasting blood sugar checks on specific days. A pharmacy medication regimen review recommended ordering current labs, including A1C levels and a Lipid Panel, which the physician agreed to. However, R15 refused to have these tests collected in June 2024. Despite the refusal in June, the medical record showed laboratory test results from October 2024, which included fasting lipids and glucose but did not include an A1C test. During an interview, RN B confirmed that A1C tests are generally conducted every three months for diabetic residents and acknowledged that there were no A1C results for R15 dating back to February 2024. This oversight indicates a failure to ensure the resident's drug regimen was free from unnecessary drugs due to the lack of appropriate laboratory monitoring.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate for a resident. During an observation, RN C prepared several medications for the resident but did not wash her hands or use hand sanitizer before setting up the medications. Additionally, RN C did not administer or apply Lexapro 5 mg and Betamethasone cream as ordered. RN C left the medication cup and MiraLAX mixture on the over-the-bed table and walked away to wash her hands, failing to ensure the resident took the medications. The medication administration record confirmed that Lexapro and Betamethasone were not administered or signed out. Interviews with LNA/DON A and MDS/RN B revealed that nurses are expected to wash their hands before entering and leaving the room and should not leave medications at the bedside.
Infection Control and Consent Deficiencies
Penalty
Summary
The facility failed to adhere to accepted infection control protocols during wound care for a resident with multiple health issues, including Alzheimer's Disease, legal blindness, and pressure ulcers. During an observation, a registered nurse (RN) did not change gloves or clean scissors between handling soiled and new dressings for the resident's wounds. The RN also reused a disposable gown that was hung inside the resident's room, which is against infection control expectations. The wound care orders specified the use of alginate dressing only on the wound bed, but the RN applied it over healthy tissue as well. Additionally, the facility did not obtain proper consent before administering a COVID-19 immunization to a resident with Huntington's disease and memory impairments, who had a legal guardian. The resident's medical record showed that the guardian had signed the declination section of the vaccine consent form, but the facility reported that verbal consent had been given. However, this verbal consent was not documented in the resident's medical record. These deficiencies highlight lapses in infection control practices and consent procedures, which are critical for ensuring resident safety and compliance with regulatory standards. The facility's failure to follow proper protocols and documentation requirements led to these findings during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted for 38 residents and visitors. During a tour of the facility on two separate occasions, the daily nurse staffing posting was not observed. In an interview, the Human Resources/Scheduler (HR) reported that the daily nurse staffing information had not been completed or posted for approximately two months. HR believed they had been informed that posting the daily nurse staffing information was no longer necessary.
Failure to Document Bi-Annual Fire Alarm Sensitivity Test
Penalty
Summary
The facility failed to provide documentation of the required bi-annual Sensitivity Test for the installed fire alarm system, as mandated by NFPA 70 and NFPA 72. During a record review on 03/25/2025, surveyors found that no documentation of this test was available, and this was confirmed through an interview with Facility Maintenance at the time of the review. The absence of this documentation indicates that the fire alarm system was not tested and maintained in accordance with the approved program requirements. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K345 - Fire alarm System The Facility failed to have the bi-annual Sensitivity Test for the installed fire system completed, putting the whole facility and all occupants at risk. The maintenance director scheduled the Smoke Detector Sensitivity Test with DeLau Fire services, this was completed on 4-14-25 with all smoker detectors passing inspection; no repair or follow-up needed. He also scheduled our next bi-annual Sensitivity Test to ensure sustained compliance. The Maintenance Director was educated on the requirements and importance of having the Sensitivity Test completed and other scheduled maintenance. The Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. The Administrator is responsible for maintaining compliance.
Failure to Provide Complete Smoke Compartmentalization
Penalty
Summary
The facility failed to ensure that smoke barriers were provided to form at least two smoke compartments on every floor as required by applicable codes. During a record review, it was found that the facility did not provide a smoke barrier map that demonstrated complete compartmentalization by smoke barriers throughout the building. The map provided did not show smoke barriers separating smoke compartments from outside wall to outside wall in each compartment, as required. This finding was confirmed during an interview with Facility Maintenance at the time of the record review. No information about specific patients, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
K 371 Facility floor plan was reviewed and revised to include smoke compartments. Floor plans in the facility will be replaced to meet requirements. Maintenance Director was educated on K371 tag that floor plan must identify smoke barrier walls. Maintenance Director will review floor plans with any changes to ensure compliance with updates. Concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Disposal of Smoking Materials at Emergency Exits
Penalty
Summary
During an outside perimeter walk of the building, surveyors observed over 100 cigarette butts discarded on the ground in the tree shrubbery and leaves in front of all emergency exits. These cigarette butts were not disposed of in noncombustible containers as required by facility smoking regulations. The observation was confirmed through an interview with Facility Maintenance at the time of the finding. The report notes that the facility failed to ensure smoking regulations were adopted and implemented to meet all required provisions, specifically regarding the proper disposal of smoking materials.
Plan Of Correction
K 741 Facility moved free standing smoking ash tray pole and picnic table to required distance from building. No smoking signs were placed in areas of concern to ward off smoking near building. Staff was educated on smoking away from the building or smoking privileges would be reviewed and possibly revoked. Maintenance director was educated on K741 smoking regulation. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Egress Door Locking Mechanism in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless compliant with special locking arrangements for clinical needs. Specifically, during an inspection, it was found that the cooler door for kitchen storage was equipped with a hasp latching mechanism and a padlock, which could allow the door to be locked from the outside. This hardware arrangement created a situation where someone inside the cooler could be locked in without a means to exit, as the locking mechanism did not meet the required standards for egress doors. The finding was confirmed through an interview with Facility Maintenance at the time of observation. The deficiency was noted to potentially affect 15 occupants in the event of an egress emergency.
Plan Of Correction
Maintenance Director adjusted the cooler door in the kitchen to ensure proper functioning. All other doors were checked and corrected as identified. The Maintenance Director was educated on K222 tag to ensure proper means of egress in the event of an emergency. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Inaccessible Hazardous Area Prevents Fire Safety Verification
Penalty
Summary
Staff were unable to provide access to a supply storage room located in the service hall between storage rooms 11 and 12 during an observation on 03/25/2025 at approximately 12:20 PM. This prevented a full inspection of the area to verify whether it was properly protected by a fire barrier with a 1-hour fire resistance rating, equipped with 3/4 hour fire rated doors, or safeguarded by an automatic fire extinguishing system as required by regulation. The inability to access the room meant that surveyors could not confirm compliance with fire safety standards for hazardous areas. This deficiency was confirmed through an interview with Facility Maintenance at the time of observation. The report specifically notes that this practice could affect 20 occupants in the event of a fire emergency, as the lack of access hindered the ability to ensure the hazardous area was adequately protected.
Plan Of Correction
Rounds being conducted during the Annual State Survey, the Maintenance director was unable to make entry into the supply closet located between rooms 11 and 12 in the service hallway, in turn not being able to ensure the automatic-closing door or the presence of an automatic fire extinguishing system, which put 20 occupants at risk. The maintenance director adjusted the door to the supply closet between rooms 11 and 12 to ensure the door would open freely with key access. The Maintenance director confirmed that the door was an automatic-closing door and was functioning properly, and there was an automatic fire extinguishing system present inside the closet. The maintenance director did a complete facility round to ensure safeguards were in place. The maintenance director was educated on K321 tag to ensure proper access to the facility, to ensure areas are protected with a fire-rated door or an automatic fire extinguishing system, and to ensure all safeguards are in place. The Maintenance director will complete bi-weekly facility rounds to ensure safeguards are in place and that all doors are functioning properly. Concerns will be addressed at the time of observation. Results of the facility rounds will be reported in QAPI monthly for 3 months. The Administrator is responsible for maintaining compliance.
Improper Smoke Detector Placement Near Airflow Source
Penalty
Summary
A deficiency was identified when a smoke detector was observed to be installed within three feet of direct airflow from an air return or supply on the ceiling near Exit Door H. This installation does not comply with the requirements of NFPA 70 and NFPA 72, which govern the proper placement and installation of fire alarm system components. The issue was confirmed during an interview with Facility Maintenance at the time of observation. The deficient practice could affect 30 occupants in the event of a fire emergency.
Plan Of Correction
Maintenance Director moved the smoke detector to an area more than 3 feet away from the air/return supply on the ceiling. All other areas were reviewed with no concerns noted. Maintenance Director was educated on K341 tag to ensure proper placement of smoke detectors from direct airflow to an air return/supply. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance of K345.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
During an inspection, it was observed that the door handle of the medication supply room had a gap measuring approximately 2 inches long by 1/4 inch wide at the handle cover. This gap was identified during a walkthrough and was confirmed by the facility's maintenance staff at the time of observation. The deficiency pertains to the requirement that doors protecting corridor openings must be capable of resisting the passage of smoke, as outlined in NFPA 19.3.6.3. The presence of the gap in the door handle area means the door does not meet the standard for smoke resistance, which could affect the safety of up to 20 occupants in the event of a fire emergency.
Plan Of Correction
K 363: The med supply door handle was corrected related to a gap that would allow smoke to pass and addressed to remedy this concern. Like areas were reviewed for areas of concern with no concerns noted at this time. Maintenance Director was educated on K363. Tag to ensure corridors openings are capable of resisting the passage of smoke. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Noncompliance with Electrical Safety Standards in Kitchen Area
Penalty
Summary
During an observation in the facility's kitchen dish tank area, a receptacle box with electrical wiring was found hanging off the wall behind the garbage disposal. The box was electrically tapped and exposed live electric wires to water, creating a situation where unintentional exposure to electricity could occur. This condition was directly observed and confirmed through an interview with Facility Maintenance at the time of the survey. The installation did not comply with NFPA 70, National Electric Code, as required, and presented a hazard to occupants in the area. No information was provided regarding specific residents or their medical conditions at the time of the deficiency.
Plan Of Correction
K511 Live wires in kitchen were addressed. Like areas were reviewed and no concerns were noted at this time. Maintenance director was educated on K511 electrical equipment complies with NFPA 70 NEC Code for unintentional exposure to electricity. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas of the facility. On several occasions, staff members were seen stepping on and killing the insects, but no formal pest control measures were observed. The Maintenance Director was not informed of the pest issue, indicating a breakdown in communication and protocol for addressing such problems. Additionally, the dining room was found to be in an unsanitary condition, with tables visibly soiled with dried food and drink spills, and trashcans overflowing with garbage. This was corroborated by resident interviews, who expressed dissatisfaction with the cleanliness of the dining room and the presence of insects. Two residents, one with hypertension and multiple sclerosis and another with Type 2 diabetes mellitus with diabetic neuropathy, were directly affected by these conditions. Both residents were moderately cognitively impaired, as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident reported seeing bugs crawling around and pointed out insects near his feet, while the other resident complained about the filthy condition of the dining room in the mornings. These observations and resident reports highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents.
Medication Administration Errors and Mismanagement of Controlled Substances
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in multiple medication errors and mismanagement of controlled substances. For Resident #18, the facility administered midodrine despite blood pressure readings exceeding the physician-ordered parameters and failed to properly document the administration of gabapentin on two occasions. Resident #6 did not receive a scheduled dose of morphine, and there was no documentation indicating that the provider was notified or any follow-up actions were taken. Resident #16 had multiple instances where gabapentin and clonazepam were not signed out or administered as required, and there was a lack of proper documentation for the disposal of refused medication. Resident #88 had discrepancies in the administration and documentation of Lyrica, including missing doses and an additional dose being administered without proper documentation. The report highlights that the facility's medication administration process did not ensure that vital signs were checked and recorded before administering medications with specific parameters. Additionally, there were multiple instances where controlled substances were not properly signed out or documented, leading to potential medication errors. The facility's policy on medication administration was not consistently followed, resulting in inaccurate documentation and potential risks to resident safety. Interviews with staff, including a Registered Nurse and the Nursing Home Administrator/Director of Nursing, confirmed the medication errors and the lack of proper documentation. The facility's policy on medication administration and the fundamentals of nursing practice emphasize the importance of accurate documentation and adherence to physician orders, which were not followed in these cases. The deficiencies identified in the report indicate a need for immediate action to address the medication administration process and ensure compliance with professional standards of nursing practice.
Failure to Secure Smoking Materials
Penalty
Summary
The facility failed to secure smoking materials per protocol. During an observation, it was noted that the door to the shower room behind the nurses' desk was open. Inside the shower room, there were two separate closets. The closet on the left had an open door and contained a plastic box with 7 packs of cigarettes and 2 lighters. Although the plastic box had a small padlock attached to its lid, the lid was not secured. During an interview, the Administrator stated that resident smoking materials were supposed to be kept in a plastic box that was double locked, with the cigarettes and lighters stored in a locked closet in the shower room. However, the closet door was not locked, and the lid of the plastic box was not secured, leading to the deficiency.
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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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