Roosevelt Park Nursing And Rehabilitation Communit
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskegon, Michigan.
- Location
- 1300 West Broadway Avenue, Muskegon, Michigan 49441
- CMS Provider Number
- 235549
- Inspections on file
- 20
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Roosevelt Park Nursing And Rehabilitation Communit during CMS and state inspections, most recent first.
Multiple instances of misappropriation of controlled substances occurred, including altered documentation, unaccounted-for doses, and administration of medications outside of prescribed times. An LPN was identified as altering narcotic counts and dispensing medications without proper documentation, affecting several residents. Additional deficiencies included dispensing medications without active orders and lack of required signatures for wastage, with staff failing to follow established procedures for controlled substance management.
A long-term care facility failed to prevent the misappropriation and diversion of narcotic medications for several residents. A nurse was found with unauthorized medications off-site, and discrepancies in medication counts were discovered after another nurse left abruptly. Ongoing issues with controlled medication administration were also identified, with the facility lacking a formal audit system to ensure proper medication handling.
The facility failed to document allegations of abuse made by two residents, resulting in incomplete medical records. One resident, with severe cognitive impairment, reported being pushed by a CNA, while another, moderately cognitively intact, reported being hit. Both cases lacked documentation of physical or psychosocial assessments related to the allegations, and staff interviews revealed an expectation for such documentation, which was not met.
The facility failed to maintain sanitary conditions in the kitchen, with dirty freezer seals and inconsistent refrigeration temperatures. A Raetone unit had a loose door seal and was low on Freon, affecting food safety. Additionally, ready-to-eat foods were improperly date-marked, and thawing procedures were not followed, violating FDA Food Code standards.
The facility failed to implement an effective infection prevention and control program, with inadequate tracking of infections and a lack of investigation during a COVID-19 outbreak. Additionally, the facility did not have an active plan for reducing the risk of Legionella in the plumbing system, with no evidence of regular flushing or testing.
The facility failed to maintain cleanliness and repair, with deteriorating cabinets, unsealed holes, debris in storage areas, and disrepair in the roof and soffit. A family member reported unclean conditions in a resident's room, including an unclean bedside commode and soiled bedding. These issues indicate a lack of consistent maintenance and cleanliness, potentially affecting resident satisfaction.
The facility failed to accommodate the needs and preferences of three residents, including not assisting a resident with mobility issues out of bed, and not responding to call lights in a timely manner. Residents reported long wait times for assistance, particularly during evening shifts, and issues with the distribution of snacks and water. These deficiencies were consistently highlighted in Resident Council Meetings over several months.
The facility was found to have fall hazards due to unsecured rubber mats in a hallway and high hot water temperatures in the central spa and dining room sinks. The clean utility/pantry room was also left unlocked with an unsecured aerosol spray can, posing additional risks. Staff were observed navigating around the hazards without addressing them.
The facility failed to follow proper tube feeding protocols for two residents. One resident's feeding equipment was not properly dated or stored, and the setup lacked necessary labeling. Another resident's head of bed was not elevated to the required degree during feeding, and the feeding setup was also improperly labeled.
The facility failed to properly store and label medications in a medication cart and storage room. An LPN was found with a cart containing improperly labeled and undated medications, and a spray bottle with an unidentified liquid. Additionally, a medication storage room had a refrigerator at an incorrect temperature and contained expired medications. A resident was found with unused eye drops left by facility nurses, which she did not administer herself.
The facility failed to provide adequate food options and meal variety for two residents, leading to dissatisfaction and unmet dietary needs. Despite having a system for residents to choose between a main entree and an alternate menu, the process was inconsistently implemented, with some menu items unavailable and repetitive meal options offered. Residents expressed frustration with the lack of variety and the requirement to request alternatives before a specific time.
A facility failed to accurately document the activated medical and financial DPOA for a resident, resulting in the potential for inappropriate delegation of rights. The resident's family members were designated as DPOA, but discrepancies in documentation led to the wrong individual being notified of health status changes. The facility's process for documenting DPOA information was not followed, contributing to the deficiency.
The facility did not provide required Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents discharged from a Medicare-covered Part A stay with benefit days remaining. The Nursing Home Administrator and Social Worker confirmed the absence of these notices, which are mandated by facility policy to inform beneficiaries of their rights and potential liabilities.
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. A resident was prescribed ciprofloxacin without a culture and sensitivity report, another was initially given an ineffective antibiotic for a UTI, and a third resident also lacked culture documentation. The DON confirmed lapses in reviewing reports and monitoring the antibiotic stewardship program.
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as the IP was also a full-time floor nurse, limiting their ability to focus on infection control duties. The Director of Nursing (DON), who lacked specialized training, covered IPCP duties when the IP was unavailable. This led to inadequate infection surveillance, including a missed COVID-19 outbreak investigation and incomplete Resident Infection Control Logs. The facility's policy required the IP to be employed at least part-time, but the facility assessment did not specify the necessary time for IPCP duties.
Failure to Prevent and Monitor Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for multiple residents, as evidenced by altered documentation and unaccounted-for doses of narcotic medications. For one resident, the Controlled Substances Proof of Use sheet showed repeated alterations in the quantity remaining, with bold overwriting of numbers to obscure previous entries. This resulted in discrepancies where more tablets were dispensed than ordered, and the documentation was manipulated to hide the actual count. Staff interviews confirmed that an agency LPN was responsible for altering the narcotic count and that these changes were not immediately detected during shift exchanges, as the counts were verbally confirmed rather than visually verified against the medication sleeves and documentation. Another resident's records revealed that an additional dose of a controlled medication was dispensed outside of the prescribed times, with no corresponding entry in the electronic medication administration record (eMAR) or the resident's electronic medical record. The missing documentation and the lack of a scheduled administration at that time indicated that the medication was unaccounted for. Further audits of medication carts did not reveal additional discrepancies, but the incident was substantiated as misappropriation based on the available evidence. Staff statements indicated that the LPN involved had a history of similar issues at other facilities. Additional deficiencies were identified for other residents, including the dispensing of controlled substances without active orders, administration of medications outside of prescribed times, and lack of required documentation for medication administration and wastage. In several cases, doses were dispensed and not recorded in the eMAR, and there was no second nurse signature to verify wastage of unused medication. Interviews with nursing staff and review of facility policies confirmed that these actions did not follow professional standards or facility procedures for controlled substance management, leading to unaccounted-for medications and the potential for ongoing diversion.
Medication Misappropriation and Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of narcotic medications for several residents, leading to a deficiency in safeguarding resident property. In one incident, a registered nurse (RN E) was found in possession of medications belonging to a resident (R8) during a police traffic stop. The medications included 17 vials of Promethazine and a hydrocodone capsule, which were not authorized for removal from the facility. The facility confirmed the misappropriation of these medications, as they were found off-site and in the possession of RN E without proper authorization. In another incident, discrepancies in the medication count were discovered after RN D abruptly left the facility without completing the required medication count. This resulted in missing doses of Norco for two residents (R7 and R3) and Tramadol for another resident (R4). The facility's investigation was inconclusive due to RN D's refusal to cooperate, including failing to submit to a drug test and provide a statement. Despite the evidence of missing medications and RN D's abrupt departure, the facility was unable to definitively conclude that RN D diverted the medications. Additionally, ongoing discrepancies in controlled medication administration were identified for three residents (R3, R4, and R5), with missing documentation for the administration of medications such as Lorazepam, Tramadol, and Oxycodone-Acetaminophen. The facility lacked a formal audit system to ensure proper medication administration and reconciliation, and the Director of Nursing (DON) had not implemented a comprehensive review process to address these discrepancies. The facility's failure to monitor and investigate these issues adequately contributed to the deficiency in protecting residents' medications from misappropriation and diversion.
Deficiency in Documentation of Resident Allegations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for providers not having an accurate and complete picture of the residents' stay. For one resident, identified as R2, the facility's records did not document an allegation made by the resident that a CNA had pushed her. Despite the resident's severe cognitive impairment and multiple diagnoses, including delusional disorders and PTSD, there was no documentation of physical or psychosocial assessments related to the allegation. Additionally, the social services notes and assessments conducted did not specify the reasons for the visits or assessments, such as whether they were routine or related to the incident. Similarly, for another resident, identified as R4, the facility's records failed to document an allegation that someone had hit her. R4, who was moderately cognitively intact, also had no documentation of physical or psychosocial assessments related to her allegation. The social services notes and assessments for R4 did not indicate the reasons for the visits or assessments, leaving a gap in the documentation of care provided following the resident's report of abuse. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, revealed that there was an expectation for nurses to document such allegations in the residents' progress notes. However, upon review, no such documentation was found in the electronic medical records of either resident. This lack of documentation was acknowledged by the Director of Nursing, who noted the need for improvement in this area. The absence of documentation related to the allegations was not rectified by the time of the survey's completion, highlighting a deficiency in the facility's record-keeping practices.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, the top portion of the door seals of a two-door Traulson freezer was found with an accumulation of crumbs and dirt debris. This issue persisted during a revisit, indicating a lack of proper cleaning and maintenance. Additionally, the internal thermometer of a Raetone refrigeration unit showed inconsistent temperatures, and a whole tomato inside the unit was found to be at an unsafe temperature. The door seal of the unit was loose, allowing light to be seen from inside, which could compromise the unit's ability to maintain safe temperatures. Further inspection revealed that the Raetone refrigeration unit was low on Freon and had icing on the thermostat, affecting its functionality. Despite these issues, potentially hazardous food was not immediately discarded or moved, as confirmed by the Dietary Supervisor. It was only after a vendor's intervention that the unit was emptied. Additionally, the facility failed to properly date-mark ready-to-eat foods, with several items found open and without discard dates, or held past their discard dates, in the hallway utility pantry. The facility also did not adhere to proper thawing procedures for time/temperature control for safety food. Frozen nutritional drinks were found in a bowl of water in the rinse compartment of a three-compartment sink, and a box of frozen nutritional drinks and ice cream was left in ambient air outside of refrigeration. These actions and inactions demonstrate a failure to comply with the 2017 FDA Food Code, which outlines necessary standards for maintaining food safety and preventing foodborne illnesses.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by inadequate tracking and surveillance of infections among residents. Three residents were identified as having been prescribed antibiotics, but their information was not accurately reflected in the Resident Infection Control Log. Additionally, the facility did not conduct a thorough investigation or implement preventative measures during a COVID-19 outbreak, failing to document essential details such as contact tracing, notifications, and interventions. The facility's infection control program was found lacking in several areas, including the absence of a comprehensive outbreak investigation and management plan. The documentation provided did not include critical information such as the notification of the Medical Director, Health Department, staff, residents, and families about the outbreak. Furthermore, there was no evidence of daily active surveillance or implementation of transmission-based precautions to prevent the spread of infection. Additionally, the facility did not have an active plan for reducing the risk of Legionella and other opportunistic pathogens in the plumbing system. The Maintenance Director was unaware of the facility's water management plan, and there was no evidence of regular flushing or testing of the water system. The facility's Water Pathogen Risk Reduction policy was not dated, and there was no indication that a water management team was in place to monitor and address potential risks.
Facility Cleanliness and Maintenance Deficiencies
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Summary
The facility failed to maintain general cleanliness and repair of the premises, leading to potential contamination and decreased resident satisfaction. During a tour of the utility pantry, it was observed that the cabinets were deteriorating due to water damage, and a large hole in the wall behind a stainless-steel panel was not sealed, allowing potential pest entry. In the storage room containing nursing and tube feeding supplies, excess debris and trash were found on the floor, and a light shield was hanging down. Additionally, a light shield cover was missing in the service hall storage room. The back portion of the roof and soffit was in disrepair, providing open access to the attic space. Several wall-mounted air conditioning units in the hallways had an accumulation of black spotted debris. A family member expressed concerns about the cleanliness of a resident's room, reporting that the bedside commode was often not cleaned, resulting in a strong odor of urine and feces. The family member also noted that the resident's bedding was not changed regularly, leaving it visibly soiled and malodorous. Despite voicing these concerns to management, improvements were inconsistent. These observations and interviews highlight the facility's failure to maintain a clean and safe environment for residents, staff, and the public.
Failure to Accommodate Resident Needs and Preferences
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Summary
The facility failed to accommodate the needs and preferences of three residents, as well as address several unmet needs reported during Resident Council Meetings. Resident #10, a male with a history of stroke and left-sided weakness, was observed to have remained in bed for extended periods without being assisted out of bed by staff, despite care plan interventions that included encouraging participation in facility life and assisting with activities. Observations over several days showed that Resident #10 was not engaged in any meaningful activities, and staff interviews confirmed that he had not been assisted out of bed due to time constraints. Resident #4, a cognitively intact female, expressed concerns about call light wait times, reporting that it could take up to an hour for her call light to be answered. She also reported that staff did not inform her of extended wait times and often had excuses for not promptly assisting her. On one occasion, she was not assisted to get up or cleaned before breakfast, which was against her usual preference. Resident #18, another cognitively intact female, reported similar issues with call light wait times, particularly during the evening shift, and described the CNAs as having bad attitudes and being unresponsive to residents' needs. The Resident Council Meetings consistently highlighted issues with slow call light response times, particularly during the second and third shifts, and problems with the distribution of evening snacks and water. These concerns were documented over several months, indicating a pattern of unmet needs and preferences among residents. The facility's policy on call light response times, which states that staff should respond within a reasonable period of no longer than 10 minutes, was not adhered to, contributing to the deficiencies observed.
Fall Hazards and High Water Temperatures Identified
Penalty
Summary
The facility failed to maintain an environment free of fall hazards and high hot water temperatures. During an observation, the clean utility/pantry room was found unlocked and accessible to self-mobile residents, containing an unsecured aerosol spray can of disinfectant cleaner. Additionally, two thick black rubber mats were observed folded and placed in the walkway, creating a tripping hazard. These mats were left in the resident hallway, causing staff and residents to navigate around them, with some staff stepping over the mats instead of removing them. This situation persisted for a significant period, with multiple staff members observed passing by without addressing the hazard. Furthermore, during a facility tour, it was discovered that the hot water temperature at the central spa hand sink reached 123.9°F, exceeding safe levels. The Maintenance Director confirmed that the water heater supplying this area was set too high and attempted to adjust the mixing valve to lower the temperature. Similarly, the hot water in the dining room sink was found to reach 126.8°F, with a point of use mixing valve that required adjustment. These findings indicate a failure to adequately monitor and control water temperatures, posing a risk to residents.
Failure to Follow Tube Feeding Protocols
Penalty
Summary
The facility failed to adhere to standards of practice for two residents receiving nutrition and hydration through feeding tubes. Resident #10, a male with a history of stroke and blindness, was observed with a syringe and plastic basin used for tube feeding that were not properly dated and stored. Additionally, the tube feeding setup lacked proper labeling, including the resident's name, date, time, and the ordered rate, as required by the facility's policy. Resident #25, a female with a history of cerebral infarction, was observed multiple times with her head of bed elevated below the recommended 30 degrees while receiving tube feeding. The feeding setup also lacked proper labeling, missing the resident's name and the time the feeding was started. These observations indicate a failure to follow the facility's policy and standard nursing practices for tube feeding management.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in one of two medication carts and one of two medication storage rooms. During an observation, an LPN was found with a medication cart containing several open bottles of artificial tears, some without dates indicating when they were opened, and other medications such as Moisture Eye drops, Fluconazole nasal spray, Azelastine nasal spray, and Dorzolamide eye drops, all lacking proper labeling or opened dates. Additionally, a large spray bottle with an unidentified clear liquid was found in the cart, which the LPN assumed was hand sanitizer. The LPN acknowledged that the medications should have been dated and not used if opened without a date. In another instance, the medication storage room near the front nursing station had a refrigerator storing insulins and other medications at an incorrect temperature of 32 degrees, with the temperature log last completed several days prior. Expired medications, including a liquid multivitamin and Cherry flavored liquid acetaminophen, were also found in the storage room. An LPN admitted to not knowing the correct refrigerator temperature and acknowledged the expired medications. Furthermore, a resident was found with unused/unopened dropperettes of cyclosporine 0.05% (Restasis) on her nightstand, which she reported were left by facility nurses, and she did not administer them herself.
Inadequate Food Options and Meal Variety
Penalty
Summary
The facility failed to provide adequate food options that accommodate resident preferences and dietary needs, as evidenced by the experiences of two residents. Interviews and record reviews revealed that the facility's dietary system was not effectively offering alternative or optional food choices. The Dietary Supervisor indicated that residents could choose between a main entree and an alternate menu, but the process relied on residents communicating their preferences to nursing staff, who would then inform the kitchen. However, the system was not consistently implemented, as some items on the alternative menu were not regularly available, and residents were not always able to receive their preferred meals. Resident #4, a cognitively intact female, expressed dissatisfaction with the quality and variety of the meals, describing them as "lousy and cold." Similarly, Resident #18, also cognitively intact, reported a lack of variety and repetitive meal options, such as being served pork for several consecutive days and receiving hot dogs as the only alternative meal. This resident also faced challenges in obtaining suitable meals for those with chewing or swallowing difficulties. The resident expressed frustration with the requirement to request alternative meals before a specific time and felt that the facility's approach did not adequately cater to individual needs.
Inaccurate DPOA Documentation Leads to Miscommunication
Penalty
Summary
The facility failed to accurately record the activated medical and financial Durable Power of Attorney (DPOA) in the medical record for a resident, leading to the potential for inappropriate delegation of resident rights. The resident, an elderly female, was admitted to the facility with family members designated as her DPOA for medical and financial decisions. However, discrepancies were found in the documentation: one family member was incorrectly listed as the primary contact for both medical and financial decisions, despite not being the legal DPOA. This resulted in the wrong individual being notified of changes in the resident's health status and medication. Interviews and record reviews revealed that the facility's process for documenting DPOA information was not followed correctly. The social worker confirmed that the contact information for each DPOA should be documented in the electronic health record and on the admission record, specifying if there are separate DPOAs for financial and medical decisions. The facility's policy on advance directives requires that a copy of the advance directive be placed in the resident's medical record upon admission, but this was not accurately done in this case, leading to the deficiency.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications to residents regarding their Medicare coverage and potential liability for services not covered. Specifically, the facility did not issue Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents who were discharged from a Medicare-covered Part A stay with benefit days remaining. During an entrance conference, a request was made for a list of such residents discharged in the past six months. Subsequently, the Nursing Home Administrator and Social Worker confirmed that they did not have the required ABN or NOMNC for the selected residents. The facility's policy mandates the issuance of these notices to inform beneficiaries of their rights and potential liabilities, but this was not adhered to in these cases.
Inappropriate Antibiotic Utilization Due to Lack of Culture and Sensitivity Reports
Penalty
Summary
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. Resident #142 was prescribed ciprofloxacin without a culture and sensitivity report to confirm its effectiveness against the bacteria. Resident #143 was initially prescribed cephalexin, which was ineffective against the urinary tract infection as indicated by the laboratory report. The resident was later switched to ciprofloxacin after a delay in treatment. Resident #144 was also prescribed ciprofloxacin without any culture and sensitivity documentation to verify its appropriateness. The Director of Nursing (DON) confirmed during interviews that there were lapses in reviewing culture and sensitivity reports upon admission and that the facility's antibiotic stewardship program required closer monitoring. The facility's policy on antibiotic stewardship outlines the roles of the Infection Preventionist and DON in coordinating and supporting antibiotic stewardship activities, including monitoring antibiotic use and ensuring prescriptions are appropriate. However, these protocols were not adequately followed, resulting in the deficiencies noted in the report.
Inadequate Infection Preventionist Role and Time Allocation
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was working at least part-time and was provided sufficient time to perform the Infection Prevention and Control Program (IPCP) duties. The Director of Nursing (DON) was listed as the Infection Control Preventionist in the Facility Assessment, but the actual IP, who was certified in infection prevention and control, was also working full-time as a floor nurse. This dual role limited the IP's ability to focus on infection control duties, as the IP did not have designated time to maintain or monitor the IPCP effectively. Interviews revealed that the IP, who took over the role after the previous IP left, did not have set hours or days for assessing, developing, implementing, monitoring, and managing the IPCP. The DON, who had not completed specialized training in infection prevention and control, was covering the IPCP duties when the IP was unavailable. This lack of dedicated time and specialized training led to inadequate surveillance and tracking of infections, as evidenced by the failure to complete an outbreak investigation for a COVID-19 outbreak and the omission of residents on antibiotics from the Resident Infection Control Log. The facility's policy required the IP to be employed at least part-time, with the amount of time determined by the facility assessment. However, the assessment did not specify the time needed for the IP to complete IPCP duties. The report highlighted deficiencies in antibiotic stewardship, as antibiotics were administered without confirming their effectiveness against identified bacteria. The DON confirmed the need for improved antibiotic stewardship and acknowledged the inadequacies in the IPCP, including the lack of an outbreak investigation and an incomplete Resident Infection Control Log.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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