Roubal Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stephenson, Michigan.
- Location
- N 306 Maple Street, Stephenson, Michigan 49887
- CMS Provider Number
- 235591
- Inspections on file
- 19
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Roubal Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with therapy recommendations for contact guard assist during ambulation fell and sustained a fractured femur when a CNA, unaware of the specific assistance level required, lost contact while attempting to position a wheelchair. The CNA was using a gait belt and walker, but did not maintain the necessary supervision as outlined in the care plan, leading to the resident's fall and injury.
Surveyors identified multiple failures in maintaining sanitary conditions in food storage and preparation areas, including debris and spills in the walk-in cooler and freezer, unclean utensils and equipment, improper sanitizer concentrations due to expired test strips, and improper air-drying of pans before storage. The Dietary Manager was often unsure about cleaning schedules and procedures, contributing to the observed deficiencies in food safety practices.
Surveyors identified failures in infection prevention and control, including improper use of Enhanced Barrier Precautions during high-contact care for two residents with indwelling devices and wounds, as well as lapses in aseptic technique during wound care. Additionally, the facility did not maintain an active water management plan to address stagnant water lines and lacked routine flushing or environmental testing to reduce the risk of waterborne pathogens.
Two residents were not provided with dignified care during personal hygiene activities, resulting in one resident being left uncovered and exposed to another resident entering through a shared bathroom. Staff failed to ensure privacy by not covering the resident or closing the bathroom door during care, and the urinary catheter drainage bag was left uncovered. The resident expressed feelings of embarrassment and helplessness due to these repeated lapses in privacy.
Two residents experienced significant discomfort due to excessive heat and persistent urine odors in their rooms. One resident, with severe cognitive impairment, was found overheated and weak, with staff and family noting the lack of temperature control and the need for a fan purchased by the family. The same resident's room had ongoing issues with urine odor and soiled linens not being promptly changed. Another resident, dependent on staff for care, reported unbearable room temperatures and was denied access to fans or air conditioning. These events reflect the facility's failure to ensure a safe, clean, and comfortable environment.
Two residents who required assistance with ADLs did not receive timely or adequate care, resulting in one being left with overgrown toenails, a full and uncovered urinary catheter drainage bag, and dried feces on his body and bedding, while another had visibly soiled, overgrown, and jagged fingernails. Staff interviews and care plan reviews confirmed gaps in addressing hygiene and grooming needs, contrary to facility policy.
A resident receiving palliative care and prescribed Fentanyl experienced multiple extended periods without a documented bowel movement, with no evidence that Miralax was administered as ordered. Facility staff, including the DON and RN, were unable to produce or explain a bowel protocol, and the facility lacked a current bowel management policy, resulting in inconsistent care for the resident.
Surveyors found that three residents with chronic heart failure who required oxygen therapy did not have their oxygen tubing changed weekly as ordered by physicians. Observations showed that the tubing had not been changed for at least ten days, and the facility's policy lacked specific guidance on tubing change frequency, despite the DON stating that weekly changes were standard practice.
Surveyors observed multiple medication administration errors, including a nurse administering a Levothyroxine tablet that had been dropped on a dirty cart, another nurse applying Voltaren gel without using the required dosing card, and improper insulin administration with a Novolog Flexpen. These actions resulted in a medication error rate of 12%, exceeding the regulatory threshold.
A group of residents and the resident council president were unaware of the procedure for accessing the most recent survey results and plan of correction. When the posted survey results were reviewed, only a draft version marked "Not Final" was available, and no plan of correction was included. The administrator confirmed the absence of the final survey and plan of correction in the publicly accessible binder.
Surveyors found that the facility did not document or post the actual hours worked by RNs, LPNs, or CNAs on the daily nurse staffing sheets, leaving required columns blank despite facility policy and federal regulations mandating this information be available and updated for each shift.
The facility did not have a current three-day emergency menu or clear procedures to ensure food and water provision for staff and patients during emergencies. The Dietary Manager was unsure how to manage food service if staff were unavailable, and the emergency plan listed a different water vendor than the one actually contracted. These deficiencies resulted in a lack of clear, updated policies for subsistence needs during emergencies.
A gate leading from the patio area was found chained shut, blocking a designated emergency exit. This obstruction was observed and confirmed by the Maintenance Director, preventing proper egress in case of emergency.
The facility did not perform or document required monthly emergency lighting tests for several months, as confirmed by record review and the Maintenance Director.
The facility did not ensure that the kitchen hood was inspected and cleaned at least semi-annually as required by NFPA 96, with records showing only one cleaning report and the hood's cleaning sticker indicating the next cleaning was overdue. This was confirmed by the Maintenance Director.
The facility did not maintain or test its fire alarm system in accordance with NFPA standards, as most smoke detectors were found out of sensitivity or unserviceable and had not been replaced. There was also confusion and lack of documentation regarding the replacement of the fire alarm control panel, with discrepancies between reported and observed equipment. Additionally, the fire alarm control panel breaker lacked a required lock to prevent unauthorized disconnection.
A review of inspection records and staff interview revealed that the facility did not repair the outside bell on the automatic sprinkler system after it was found inoperable during the most recent annual inspection. The maintenance director confirmed the issue remained unresolved.
The facility did not transmit the fire alarm signal during required fire drills on the third shift or the following day for multiple instances, as confirmed by the Maintenance Director. This action did not meet regulatory requirements for conducting fire drills, which must include the transmission of a fire alarm signal and simulation of emergency fire conditions.
The facility did not ensure portable fire extinguishers were properly inspected and maintained according to NFPA 10, with one extinguisher lacking inspection records and another found overpressurized. These issues were confirmed by the Maintenance Director and could impact 15 occupants.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. After one RN resigned and another went on leave, the facility was left without adequate RN staffing despite attempts to recruit more RNs.
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in managing RSV and Norovirus outbreaks. The Infection Preventionist did not adequately track or document employee and resident illnesses, and no formal investigation was conducted for the outbreaks. This lack of adherence to established policies contributed to the facility's inability to control the spread of infections effectively.
The facility failed to ensure a qualified Infection Preventionist was working at least part-time and provided sufficient time to manage the Infection Prevention and Control Program. The designated IP was responsible for three facilities and primarily worked remotely, leading to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. Specific residents did not receive necessary immunizations, and there was a lack of ongoing surveillance and outbreak investigations.
The facility failed to make grievance forms accessible to residents and family members and did not follow up on a resident's concerns about being woken up at night, which exacerbated his anxiety. The resident's care plan did not reflect his preferences for care timing, leading to ongoing dissatisfaction.
The facility failed to report and investigate an injury of unknown origin for a resident with multiple diagnoses, including alcohol-induced dementia and high blood pressure. Despite the resident experiencing increased right leg pain and an x-ray revealing a possible fracture, the facility did not report the injury to the State Agency, hold a Trigger Call, or conduct an internal investigation, violating their policies and procedures.
The facility failed to follow professional standards for medication administration for two residents, resulting in medications being given outside of physician-ordered parameters. One resident received metoprolol despite low blood pressure and heart rate, while another received amlodipine despite low blood pressure readings.
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. One resident with dementia and a history of falling experienced an unwitnessed fall resulting in a scalp laceration and hematoma, with no neurological assessment or new safety interventions. Another resident with dementia and orthostatic hypotension experienced multiple unwitnessed falls, with no neurological exams or new interventions added to the care plan to prevent future falls.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. Antibiotics were administered based on urine dip tests without waiting for culture results, and documentation did not meet McGeer Criteria for initiating antibiotics.
The facility failed to provide pneumococcal immunizations per CDC recommendations for two residents. One resident had not received the vaccine since 2016 despite consent and an order, while another had no documentation of receiving the last influenza or pneumococcal vaccines. The Infection Preventionist confirmed the immunizations were not up to date.
Failure to Provide Adequate Supervision and Proper Use of Assistive Devices Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and proper use of assistive devices for a resident who was at risk for falls. The resident, who had therapy recommendations for ambulation with a front-wheeled walker, contact guard assist, and a wheelchair to follow, was being assisted by a CNA during ambulation. The CNA reported using a gait belt and gripper socks, with one hand on the gait belt and the other pulling the wheelchair behind. When the resident expressed fatigue and a desire to sit, the CNA attempted to position the wheelchair but lost contact with the resident, resulting in the resident losing balance and falling sideways into a wall. The resident sustained a right femur fracture and required surgical intervention. Documentation and interviews revealed that the CNA was not fully aware of the specific contact guard assist requirement and believed the resident was an assist of one during ambulation. The incident report and progress notes confirmed that the plan of care, which required close supervision and specific assistive techniques, was not fully adhered to at the time of the fall. The lack of consistent application of the recommended supervision and assistive device use directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Sanitary Food Service Conditions and Proper Sanitization
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions and professional standards for food service safety in the facility's kitchen and food storage areas. During a tour of the walk-in cooler, there was an accumulation of debris on the wire rack shelving, a dried yellow spill, and paper trash under racks and along the floor perimeter. The walk-in freezer also contained paper trash debris from date marking stickers. In the clean utensil drawer, crumbs were found along the back wall, and the Dietary Manager was unsure how often this area was cleaned. The stand-up mixer, covered with a plastic bag to keep it clean, had dried food debris on its underarm. Both the manual and electric can openers had significant accumulations of rust, pitting, and dark debris, and the pantry microwave had visible food debris on its interior top surface. Further deficiencies were noted in the facility's sanitation practices. Staff obtained sanitizer from the janitor's sink and filled spray bottles, but the test strips available for checking sanitizer concentration were expired. Testing revealed that one sanitizer spray bottle had a concentration of 0 to 50 ppm, while a bucket prepared by the Dietary Manager exceeded 500 ppm, indicating inconsistent and improper sanitizer levels. The Dietary Manager was unsure about the cause of this inconsistency. Additionally, in the clean pots and pans storage area, several pans were found stacked while still wet, without proper air drying, contrary to required procedures. These observations were corroborated by interviews with the Dietary Manager, who acknowledged uncertainty regarding cleaning schedules and procedures for several areas and equipment. The report references specific sections of the 2022 FDA Food Code, highlighting the requirements for cleanliness of food-contact and non-food-contact surfaces, proper use and testing of sanitizing solutions, and the necessity for air-drying equipment and utensils before storage. The documented failures in cleaning, sanitizing, and storage practices represent a deficiency in maintaining food safety standards as required by federal regulations.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures according to current guidelines and professional standards for two residents. For one resident with an indwelling urinary catheter and requiring maximal assistance, staff did not consistently use Enhanced Barrier Precautions (EBP) during high-contact care activities such as emptying the urinary catheter drainage bag and transferring the resident. Observations showed that staff either did not wear protective gowns as required or were unclear about when EBP should be used, despite CDC signage indicating the need for gowns and gloves during specific care activities. Additionally, the resident's care plan did not include interventions related to EBP, and the facility's infection control policy lacked procedures for EBP use. Another resident with end-stage renal disease, dementia, and a deep tissue injury was observed receiving wound care without staff donning gowns for EBP, as indicated by posted CDC guidance. During the wound care procedure, the nurse failed to maintain aseptic technique, including contaminating sterile supplies with gloved hands that had touched environmental surfaces, and retrieving gloves from a scrub pocket considered unclean. The nurse acknowledged these lapses in infection control practices during an interview. The facility also lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. Observations revealed stagnant water lines, unused fixtures, and discolored water from infrequently used faucets. Staff interviews confirmed the absence of a routine flushing schedule for water fixtures and no environmental water testing as part of the water management program. The facility's water management policy referenced control measures and corrective actions but did not specify their implementation or documentation.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
The facility failed to provide dignified care and ensure privacy for two residents during personal care activities. One resident, who was admitted with diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression, was completely dependent on staff for all transfers, mobility, and personal care due to an indwelling urinary catheter and bowel incontinence. The resident was cognitively intact and expressed feelings of embarrassment and helplessness related to his dependence on staff and lack of privacy during care. During morning care, two CNAs were observed providing incontinence care to the resident, who was left uncovered and exposed while stool was being cleansed from his body. The shared bathroom door between the resident's room and an adjoining room was left open, allowing another resident to enter and view the exposed resident during care. The CNAs did not offer or assist with covering the resident at any time during the observation. Additionally, the urinary catheter drainage bag was not covered, and the resident's body was partially exposed during a transfer from bed to a recliner, with the bathroom door again left ajar. The Director of Nursing confirmed that the resident did not use the bathroom due to incontinence and catheter use, but staff used the bathroom during care provision. The DON acknowledged the importance of keeping the door closed to ensure privacy and dignity for both residents sharing the bathroom. The observations and interviews revealed repeated failures to maintain the resident's privacy and dignity during care, as required by resident rights regulations.
Failure to Maintain Safe, Comfortable, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by two residents experiencing significant discomfort due to excessive heat and persistent urine odors in their living areas. One resident, with multiple diagnoses including dementia and end-stage renal disease, was found to be overheated and weak after wearing multiple layers of clothing on a hot day. Staff and the resident's power of attorney reported that the room was extremely hot, and the facility did not provide a fan, requiring the family to purchase one. The environmental services director confirmed there was no monitoring of room temperatures, and the facility had no documentation to ensure temperatures remained within regulatory limits. Additionally, the same resident's room was repeatedly noted to have a strong urine odor, with wet bed sheets and soiled pads left unaddressed after the resident was moved from bed. Staff acknowledged the presence of urine odor and wet linens, and the director of nursing confirmed that such linens should have been changed immediately. The resident's representative reported ongoing issues with urine odors and soiled pads, indicating a pattern of inadequate housekeeping and maintenance services. Another resident, who was dependent on staff for mobility and hygiene, reported that the temperature in his room was unbearable on several days, and requests for a fan or air conditioning were denied. The resident stated that he preferred to keep his door closed for privacy, which exacerbated the heat, and he was uncertain if a window air conditioner he ordered would be permitted. These findings demonstrate the facility's failure to provide adequate temperature control and maintain odor-free, comfortable living conditions for its residents.
Failure to Provide Timely ADL Care and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate activities of daily living (ADL) care for two dependent residents. One resident, who was cognitively intact and had multiple diagnoses including diabetes and bowel incontinence, was observed with overgrown toenails, a full and uncovered urinary catheter drainage bag containing dark yellow urine, and dried feces on his bedding and body. The resident had not been checked or changed since the previous evening, as staff reported honoring his request not to be disturbed overnight, but did not check on him at the beginning of the morning shift. The resident's care plan did not address bowel incontinence or nail care related to his diabetes diagnosis, and staff confirmed that nail care was the responsibility of licensed nurses, with no podiatrist available. Another resident, who required substantial assistance with bathing and personal hygiene and had mild cognitive impairment, was observed with visibly soiled, overgrown, and jagged fingernails. The resident's nails had dark coloring under the nail beds and were unkempt, with one thumbnail appearing sharp and jagged. The resident expressed resignation about the state of his nails when asked if he would prefer to have them cleaned and trimmed. His care plan noted a self-care performance deficit and the need for assistance with personal hygiene and oral care. Review of the facility's ADL policy indicated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, observations and interviews revealed that these services were not consistently provided, resulting in residents being left with unmet hygiene and grooming needs.
Failure to Implement Bowel Protocol for Resident on Constipating Medication
Penalty
Summary
The facility failed to consistently implement a bowel protocol program for one resident who was admitted with chronic systolic congestive heart failure, protein-calorie malnutrition, and was receiving palliative and hospice care. The resident was prescribed Fentanyl, a medication known to cause constipation, and had a physician's order for Miralax to be administered as needed for constipation. However, medical record review showed multiple extended periods—ranging from four to over five days—without a documented bowel movement, and no documentation that Miralax was administered during these times. The Medication Administration Record for the month showed no evidence that the medication was given, despite the absence of bowel movements. Interviews with facility staff, including the DON, NHA, and a registered nurse, revealed that there was confusion and lack of clarity regarding the bowel protocol. The DON and NHA could not produce a current bowel protocol or explain the existing one, and the RN was unable to locate the protocol or specify the order of interventions. The Medical Director confirmed that the expectation was for staff to notify her after three days without a bowel movement and to administer Miralax as ordered, but this was not done. The facility did not have a current bowel policy in place at the time of the survey, and staff were unable to demonstrate consistent implementation of bowel management for the resident.
Failure to Maintain Sanitary Oxygen Tubing per Physician Orders
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of respiratory care, specifically regarding the maintenance of sanitary oxygen tubing for three residents who required oxygen therapy. Each resident had physician orders specifying that oxygen tubing should be changed weekly, with the tubing dated and initialed at each change. However, observations revealed that the oxygen tubing for all three residents had not been changed for at least ten days, as the tubing was last dated as changed on 6/16/25, despite observations occurring on 6/24/25 and 6/26/25. The residents involved had diagnoses including chronic diastolic and systolic congestive heart failure and were documented as requiring oxygen therapy per their care plans and physician orders. Interviews with the Director of Nursing confirmed that the facility's practice was to change oxygen tubing weekly, but the facility's written policy on oxygen administration did not specify the frequency for changing tubing. The lack of adherence to physician orders and the absence of clear policy guidance contributed to the failure to maintain sanitary oxygen tubing for the affected residents.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 12% based on 3 errors out of 25 observed opportunities. One incident involved a registered nurse preparing Levothyroxine for a resident, during which the tablet was dropped onto the top of a medication cart that was acknowledged as dirty and not disinfected. The nurse picked up the tablet with gloved hands, without performing hand hygiene, and administered it to the resident instead of discarding it and using a new tablet, as required. Another incident involved a nurse preparing Diclofenac Sodium (Voltaren) gel for a resident's knees without using the required dosing card to measure the correct 4-gram dose. The nurse was unaware of the dosing card's existence and could not confirm the correct amount was administered. A third incident involved the administration of fast-acting insulin using a Novolog Flexpen, where the nurse changed the needle after priming and did not follow the manufacturer's instructions to keep the needle in the skin for six seconds after the dose counter reached zero, potentially resulting in an incomplete dose. These actions were observed and confirmed through interviews and record reviews.
Failure to Provide Accessible Survey Results and Plan of Correction
Penalty
Summary
The facility failed to honor residents' rights to examine the results of the most recent survey conducted by Federal or State surveyors, as well as the associated plan of correction. During a confidential group meeting with six residents, it was revealed that none of the residents were aware of the procedure for accessing the survey results or knew where these results were posted. The resident council president also confirmed a lack of knowledge regarding the location of the last survey results. Upon inspection with a resident, a binder containing survey results was found hanging on the wall. However, the most recent survey displayed was marked "Not Final" on each page, and there was no plan of correction included. The Nursing Home Administrator confirmed that the binder did not contain a final copy of the last annual survey or the required plan of correction, indicating that the facility did not make these documents readily accessible as required.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. On multiple occasions, surveyors observed that the Nurse Staffing Sheets posted in a prominent location did not include the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Certified Nurse Aides (CNAs) for any shift. The columns designated for recording these actual hours were left blank for the reviewed dates. This omission was confirmed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who acknowledged that the actual hours worked were not documented as required. A review of the facility's own policy indicated that the Nurse Staffing Sheet should be updated daily to reflect actual hours worked, including adjustments for staff absences or call-outs, and should include all nursing staff paid by the facility, including contract staff. Despite this policy, the posted sheets did not contain the required information, resulting in noncompliance with federal regulations regarding nurse staffing data transparency.
Failure to Establish and Maintain Emergency Subsistence Policies and Procedures
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during emergencies, as required by federal regulations. During an interview, the Dietary Manager was unable to confirm the existence of a three-day emergency menu and stated that food provisions would be based on the regular menu cycle. The Dietary Manager also expressed uncertainty about how the facility would manage food service if dietary staff were unable to work due to weather conditions. It was noted that a three-day emergency menu had previously existed but was not re-established after a change in food vendors. Additionally, a review of the facility's emergency preparedness plan revealed inconsistencies regarding water supply arrangements. The written policy indicated reliance on one vendor for emergency water provision, while the Administrator reported having a contract with a different vendor not reflected in the plan. These deficiencies indicate a lack of clear, updated, and actionable procedures to ensure the availability of food, water, and other essential resources for staff and patients in the event of an emergency.
Obstructed Emergency Exit Due to Chained Patio Gate
Penalty
Summary
A deficiency was identified when, during an observation, a gate providing exit from the patio area was found to have a chain wrapped around it and the adjoining fence, which prevented the gate from being used as an emergency exit. This obstruction to the means of egress was discovered at approximately 11:37 AM and was confirmed by the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Conduct Monthly Emergency Lighting Tests
Penalty
Summary
The facility failed to conduct monthly emergency lighting tests for the months of June 2024 through October 2024, as required by regulations. This was identified during a record review on June 25, 2025, when no documentation of the required testing was available. The Maintenance Director confirmed that the records for these months were not provided at the time of the survey exit. This deficiency could affect all occupants in the event of a power failure, as automatic emergency lighting is required to be tested regularly to ensure proper function.
Failure to Perform Required Semi-Annual Kitchen Hood Cleaning
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, the kitchen hood was not inspected or cleaned at least semi-annually as required. Record review showed only one hood cleaning report dated October 2024, and the cleaning sticker on the hood indicated that the next cleaning was due in April 2025. This deficiency was confirmed during an interview with the Maintenance Director at the time of discovery. No information was provided regarding specific patients or their medical conditions in relation to this deficiency.
Deficient Fire Alarm System Testing, Maintenance, and Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards. During record review, it was found that the most recent annual fire alarm inspection and sensitivity reports indicated that most smoke detectors were out of sensitivity or unserviceable and needed replacement. When questioned, the Maintenance Director (MD) confirmed that these issues had not been corrected. Documentation provided showed that some components such as duct detectors, key switches, and panel parts were replaced, but there was confusion regarding whether the fire alarm control panel (FACP) itself had been replaced. Further review revealed a discrepancy between the inspection report, which listed an Edwards EST Panel, and the observed installed panel, which was a Kidde FX Series. No evidence was provided to clarify if the deficiencies noted in the inspection and sensitivity reports had been addressed or to explain the discrepancies regarding the FACP. Additionally, it was observed that the breaker for the Fire Alarm Control Panel did not have a device to prevent unauthorized disconnection, such as a circuit breaker lock, as required by NFPA 72. This finding was confirmed by the MD at the time of discovery. No further information was provided to indicate that this issue had been resolved.
Failure to Repair Sprinkler System Alarm After Inspection
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review on June 25, 2025, it was found that the most recent annual sprinkler inspection, dated March 25, 2025, documented that the outside bell failed to operate. An interview with the maintenance director confirmed that this issue had not been fixed. This deficiency was identified through both documentation and staff confirmation.
Failure to Transmit Fire Alarm Signal During Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with regulatory requirements, specifically by not transmitting the fire alarm signal during fire drills on the third shift or immediately the next day for several documented dates. This deficiency was identified through record review and confirmed by the Maintenance Director. The report notes that fire drills are required to include the transmission of a fire alarm signal and simulation of emergency fire conditions, but on multiple occasions, this procedure was not followed as required.
Failure to Maintain and Inspect Portable Fire Extinguishers per NFPA 10
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were selected, installed, inspected, and maintained in accordance with NFPA 10 standards. During an observation on June 25, 2025, a fire extinguisher located in the patio area was found to have no record of inspection. Additionally, another fire extinguisher located behind the 200 wing nurses station was observed to be overpressurized. These deficiencies were confirmed by the Maintenance Director at the time of discovery. The deficient practices could affect 15 occupants in the event of a fire, as noted in the findings.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported that the facility had 2 RNs employed in addition to the DON until one RN resigned on 3/08/2024. Despite attempts to recruit more RNs, no new hires were made. The facility assessment indicated that staffing should include two full-time RNs working 10-hour shifts, 4 days a week, with coverage 7 days a week. However, the March 2024 master schedule showed that after the resignation, the facility was left without an RN for the required hours starting on 3/16/2024. The April 2024 schedule further reflected that the remaining RN began a leave of absence on 4/24/2024, exacerbating the staffing deficiency.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in preventing, identifying, reporting, investigating, and controlling infections and communicable diseases among residents, staff, volunteers, and visitors. Specifically, the facility did not adequately investigate and document outbreaks of RSV and Norovirus that occurred between December 2023 and March 2024. The Infection Preventionist, DRC C, acknowledged that employee and resident illnesses were not tracked on a specific surveillance tool but were instead scattered across various communication platforms and records, making it difficult to manage and control the outbreaks effectively. During interviews, it was revealed that the Director of Regulatory Compliance (DRC) C, who was responsible for infection surveillance, found it challenging to determine the validity of employee call-ins and to gather additional information from employees. The Previous Director of Nursing (PDON) D confirmed that no formal investigation into the RSV and Norovirus outbreaks was completed, and no documentation was available to confirm that an outbreak investigation had been conducted. This lack of documentation and follow-up indicates a significant gap in the facility's infection control practices. The review of the Employee Line Listings from January to May 2024 showed multiple instances where employees called off work due to illness without any follow-up or tracking documentation to determine if residents had been exposed to an illness. Additionally, the facility's policies on infection outbreak response and investigation, infection prevention and control program, and employee work restrictions were not adhered to, as evidenced by the lack of outbreak investigation and inadequate tracking of employee illnesses. This failure to follow established policies contributed to the facility's inability to control the spread of infections effectively.
Inadequate Infection Preventionist Presence and Oversight
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, provided sufficient time to perform the IP role, and was present to properly manage the Infection Prevention and Control Program (IPCP). The Director of Regulatory Compliance (DRC) was designated as the IP for the facility but was responsible for overseeing three facilities and primarily performed her duties remotely. The DRC was only physically present at the facility one to two days a week, which was insufficient to meet the requirements of the IPCP. This lack of adequate presence and oversight led to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. The facility's Antibiotic Stewardship Program was not properly implemented, as evidenced by the treatment of three residents with antibiotics without appropriate indications for use. Additionally, the IP did not ensure that eligible residents received the pneumococcal vaccine, and there was a failure to keep all resident immunization statuses up to date. Specific residents were identified as not having received the necessary immunizations, highlighting the gaps in the facility's infection control practices. Furthermore, the facility's Infection Control Program lacked ongoing surveillance for employee illnesses and did not conduct outbreak investigations for significant events, such as an RSV outbreak and a Norovirus outbreak. The facility's policy outlined the responsibilities of the IP, including surveillance, reporting, and managing infections, but these were not adequately fulfilled due to the insufficient presence and involvement of the designated IP. This failure to adhere to the established policies and guidelines resulted in significant lapses in infection prevention and control within the facility.
Failure to Provide Accessible Grievance Forms and Follow Up on Resident Concerns
Penalty
Summary
The facility failed to make grievance forms readily available to all residents and family members, and did not follow up with one resident's grievances. Observations on multiple dates revealed that the plastic tray labeled for grievance forms near the nurses' station was consistently empty and situated at a height inaccessible to residents in wheelchairs. Additionally, there were no instructions on the posting regarding who would follow up on the grievances and the expected time frame for follow-up. An LPN was unable to locate any grievance forms when asked, indicating a systemic issue in the availability of these forms. A resident, who was cognitively intact, reported dissatisfaction with the follow-through on his concerns about being woken up at night, which exacerbated his anxiety. The resident had submitted grievances about being woken up early to clean his fecal collection container and requested that this care be performed between 7 AM and 3 PM. However, the care plan did not reflect these preferences, and there was no indication that the resident was content with the plan of care. The resident's care plan was updated to include a note about his changing preferences, but the specific request to sleep in until he naturally wakes up was not addressed, leading to ongoing dissatisfaction and anxiety for the resident.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement policies and procedures for reporting an injury of unknown origin for a resident (R16). R16 was admitted with multiple diagnoses, including non-traumatic subarachnoid hemorrhage, rhabdomyolysis, alcohol-induced dementia, high blood pressure, weakness, and hearing loss. On 1/25/24, a progress note indicated that R16 was very weak, unsteady, and experiencing increased right leg pain. The resident was sent to the hospital for an x-ray, which revealed a deformity of the right pubic bone that could relate to an acute or chronic fracture. A follow-up evaluation confirmed a fracture of multiple pubic rami with routine healing. Despite these findings, the facility did not report the injury of unknown origin to the State Agency, did not hold a Trigger Call, and did not conduct an internal investigation into the injury. During interviews, the Director of Nursing and the Nurse Consultant confirmed that there was no investigation into the fracture identified in R16's x-ray. The facility's policies, including the Trigger Event policy and the Abuse and Neglect Policy, require reporting all injuries of unknown origin to the department of public health and conducting internal investigations. However, these procedures were not followed in this case, leading to the deficiency. The failure to report and investigate the injury of unknown origin was a clear violation of the facility's policies and procedures designed to protect residents' health and welfare.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for two residents, resulting in medications being administered outside of the physician-ordered parameters. Resident #6, a [AGE] year-old female with hypertension, had multiple instances where her blood pressure and heart rate were below the prescribed thresholds, yet metoprolol was still administered. Specifically, on 5/1/24, her blood pressure was 98/60; on 5/2/24, her heart rate was 64; and on 5/5/24, her blood pressure was 104/54 with a heart rate of 58, but the medication was given each time regardless of these readings. Resident #36, a [AGE] year-old male with hypertension, also experienced similar issues. His April Medication Administration Record revealed that amlodipine was administered despite his blood pressure being below the ordered parameters on multiple occasions. For instance, on 4/9/24, his blood pressure was 108/70; on 4/10/24, it was 110/70; and on 4/19/24, it was 102/80. Additionally, on 4/25/24, his blood pressure readings were 108/58 and 98/54, yet the medication was still administered. The Director of Nursing acknowledged that the nursing staff did not follow the physician's orders and stated that the staff would receive education to ensure compliance with medication administration protocols.
Failure to Implement Post-Fall Assessments and Safety Interventions
Penalty
Summary
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. Resident #6, a female with dementia and a history of falling, experienced an unwitnessed fall resulting in a scalp laceration and hematoma. Despite the severity of the injury, no neurological assessment or post-fall assessment was conducted, and no new safety interventions were implemented. Additionally, there were no orders for nursing to monitor and assess the resident's scalp laceration, contrary to the facility's policy for head injuries. Resident #14, who had diagnoses including dementia and orthostatic hypotension, experienced multiple unwitnessed falls. After a fall in the bathroom and another in his room, no neurological exams were conducted, and no new interventions were added to the care plan to prevent future falls. The care plan did not address the causative factors of the falls, and subsequent progress notes lacked details surrounding the incidents. The facility's failure to follow their own policies for post-fall assessments and care planning contributed to the deficiencies noted by the surveyors.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in inappropriate antibiotic use for three residents. Resident #14 was administered Cipro for a suspected urinary tract infection (UTI) based on a urine dip test, without waiting for culture results. The culture later indicated contamination, and the antibiotic was discontinued after three doses. Documentation did not provide adequate symptoms to meet McGeer Criteria for initiating antibiotics prior to culture results. Resident #18 exhibited confusion and unusual behavior, leading to a urine dip test that was positive for leukocytes, nitrates, and blood. Despite not meeting McGeer Criteria, the resident was started on nitrofurantoin before culture results were available. The culture later showed resistance to the prescribed antibiotic, necessitating a change to Amoxicillin. Documentation did not justify the initial antibiotic use based on McGeer Criteria. Resident #6 showed increased confusion and hallucinations, prompting a urine dip test that was positive for leukocytes and nitrites. An antibiotic was started before culture results, which later indicated contamination. The facility's documentation did not provide sufficient symptoms to meet McGeer Criteria for initiating antibiotics. The Director of Regulatory Compliance confirmed that the facility's antibiotic stewardship program was not followed as required, leading to inappropriate antibiotic use.
Failure to Provide Pneumococcal Immunizations Per CDC Recommendations
Penalty
Summary
The facility failed to provide the pneumococcal immunization per consent and CDC recommendations for two residents. Resident #37, a female admitted on [DATE], had not received a pneumococcal vaccine since 9/9/2016, despite having a signed consent dated 4/1/24 and an order to administer the vaccine every 5 years. Resident #191, a female admitted on [DATE], had no documentation of receiving the last influenza or pneumococcal vaccines, even though a signed consent was provided on 5/1/24 and an order to administer the influenza vaccine annually was in place. The Director of Nursing reported that the Director of Regulatory Compliance, who is also the Infection Preventionist, was responsible for the immunization program but was unable to locate the immunization tracking information. The Infection Preventionist confirmed that the pneumococcal immunizations were not up to date and was in the process of updating the residents' immunization status. The facility's policies on infection prevention and control, as well as pneumococcal vaccination, were not followed, leading to the deficiency in providing the required immunizations.
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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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