Schnepp Senior Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Louis, Michigan.
- Location
- 427 East Washington, St. Louis, Michigan 48880
- CMS Provider Number
- 235384
- Inspections on file
- 19
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Schnepp Senior Care And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple chronic conditions was given Metoprolol without required blood pressure monitoring on several occasions, including one instance where the recorded blood pressure was below the physician-ordered threshold. The DON confirmed that vital signs were not consistently documented prior to medication administration, contrary to both physician orders and facility policy.
Two residents with severe dementia were found in a situation suggestive of possible sexual abuse, with one resident discovered naked and the other pulling up her pants. Although the incident was reported internally and assessed by a nurse, it was not promptly reported to the abuse coordinator or the State Agency, despite both residents being unable to consent. This failure to report the suspected abuse in a timely manner resulted in a deficiency.
A resident with multiple comorbidities was admitted with several pressure injuries, but staff failed to accurately assess, document, and initiate treatment for these wounds. The initial nursing assessment lacked details and treatment orders, and subsequent documentation was incomplete. A new wound developed and was not properly assessed or measured, and the resident reported not receiving wound care as ordered, resulting in the worsening of a pressure injury.
A resident who required substantial assistance with toileting and hygiene reported receiving rough and hurried care from staff, leading to feelings of being unimportant. Several other residents described frequent delays in call light response, with staff often turning off call lights and failing to return to complete care, resulting in extended waits for assistance with basic needs. These issues were documented over several months and affected multiple residents, despite facility policies and staff training intended to address them.
A resident with C. diff infection was not provided proper infection control as staff failed to use required PPE and did not perform hand hygiene with soap and water as per facility policy. Both a physical therapy assistant and a CNA either used hand sanitizer instead of soap and water or did not use PPE when assisting the resident, despite being aware of the correct procedures.
Two residents with dementia were involved in an incident where one resident inappropriately kissed another, and staff failed to notify the responsible parties as required by facility policy. Despite internal reporting among staff and ongoing inappropriate behaviors by the resident, there was no documentation or evidence that the responsible parties were informed of the event.
Two residents were involved in an incident where one resident with dementia and behavioral issues kissed another resident without consent in a supervised activity room. Although the event was witnessed and reported internally to nursing leadership, it was not reported to the State Agency as required by facility policy, and no formal investigation or documentation was completed.
Two residents with dementia were involved in an incident where one was observed kissing another inappropriately. Staff notified facility leadership, but no formal investigation was initiated, and the event was not reported to authorities as required by policy. The male resident had a history of similar behaviors, yet the facility did not document interviews or conduct a thorough inquiry.
A facility failed to accurately document a resident's behavioral symptoms in the MDS assessment, despite evidence of aggressive behaviors in the EMR. The resident, diagnosed with Alzheimer's and Dementia, exhibited behaviors such as yelling and spitting, which were not reflected in the MDS, potentially affecting the development of an individualized care plan.
A facility failed to perform ordered pressure ulcer interventions and adequately monitor a resident's pressure ulcer, leading to potential worsening of the condition. The resident, admitted with a foot ulcer and peripheral vascular disease, was not consistently provided with a foam boot as required. Weekly documentation and pictures of the wound were not maintained, and staff were unaware of the wound's status. The wound nurse practitioner confirmed the wound was still open, contradicting facility records.
A facility failed to ensure a physician reviewed a pharmacy recommendation for a resident on Mobic and Eliquis, highlighting potential serious side effects. The pharmacy's recommendation was not documented in the resident's EMR, and the Director of Nursing confirmed no benefit/risk analysis was conducted by the physician. This oversight could impact the resident's health, given their medical history.
A resident with multiple health conditions was prescribed Mobic and Eliquis concurrently, despite a pharmacist's recommendation for a benefit/risk analysis due to potential cardiovascular and gastrointestinal risks. The facility failed to document any analysis or physician's note addressing this recommendation, resulting in the potential for unnecessary medication use over several months.
The facility failed to maintain accurate medical records for two residents, leading to potential miscommunication. One resident's records incorrectly documented the use of a foam boot, while another resident's records lacked a required benefit/risk analysis for concurrent medication use. The Director of Nursing confirmed the absence of necessary documentation, highlighting a breach in the facility's policy and nursing documentation standards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Blood Pressure Parameters Before Administering Antihypertensive Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, hypertension, type 2 diabetes, and chronic kidney disease was administered Metoprolol without proper assessment of physician-ordered parameters. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110 or pulse was less than 60. However, review of the electronic medication administration record (eMAR) showed that the resident received Metoprolol multiple times without blood pressure monitoring prior to administration. On one occasion, the resident's blood pressure was documented as 97/61, which was below the ordered threshold, yet the medication was still administered. The Director of Nursing confirmed that blood pressure readings were not consistently documented before medication administration, as required by both physician orders and facility policy. The facility's policy mandates that vital signs be obtained and recorded as necessary prior to medication administration, but this was not followed in the resident's case.
Failure to Timely Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents, both with severe dementia and significant cognitive impairment. A certified nurse aide discovered a female resident pulling up her pants and a male resident, naked and with an erection, in the same room. The incident was reported to the floor nurse, who then contacted the Clinical Care Coordinator/Registered Nurse (CCC/RN). The CCC/RN assessed both residents and found no physical signs of sexual intercourse or injury but did not report the incident to the abuse coordinator as required. The Nursing Home Administrator/Abuse Coordinator (NHA/AC) was not informed of the incident until the following morning during a routine meeting and only became fully aware of the details after a concerned staff member called later that day. The incident was not reported to the State Agency, despite both residents being unable to consent due to cognitive impairment and the situation meeting the definition of an alleged violation. The failure to report the suspected abuse in a timely manner constituted the deficiency.
Failure to Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, document, and initiate treatment for a resident with multiple pressure injuries upon admission. The resident, who had a history of dementia, hypertension, type 2 diabetes, and chronic kidney disease, was admitted with a stage 1 pressure injury to the coccyx, bruising to the left elbow, and pressure injuries to both feet. The nursing admission assessment did not specify the stage or measurements for the toe injuries, and there was no treatment order for the coccyx wound. Additionally, the physician's admission note did not mention any of the identified wounds, and there was no ongoing documentation or monitoring of the coccyx pressure injury in the nursing progress notes or skin/wound assessments for several days following admission. Subsequent documentation revealed that the resident developed moisture-associated skin damage (MASD) to the coccyx and buttocks, with a new wound identified later, but without detailed assessment or documentation of the wound's characteristics. During an observation, a probable stage 2 pressure injury was found near the anus, and the nurse did not measure the wound. The resident reported that wound care was not provided every shift as ordered. These failures in assessment, documentation, and timely intervention resulted in the worsening of the resident's coccyx wound.
Failure to Provide Dignified and Timely Personal Care
Penalty
Summary
The facility failed to provide personal care in a dignified manner for one resident and did not provide timely personal care and assistance for eight other residents. One resident with Parkinson's disease and heart failure, who was cognitively intact and required substantial assistance with toileting and hygiene, reported experiencing rough and hurried care from a female staff member. The resident described feeling as if he was 'thrown around in bed' during care, attributing the roughness to the staff being hurried rather than intentionally harmful. This resident reported such rough care occurred about once a week and expressed that it made him feel unimportant. The facility's Director of Nursing was still investigating the complaint at the time of the survey. Multiple residents reported issues with delayed responses to call lights and staff not returning to complete care after initially responding. Resident Council meeting minutes over several months documented ongoing complaints about long call light response times, inaccessible call lights, and staff turning off call lights without meeting residents' needs. Residents described situations where staff would turn off the call light, promise to return, but then fail to do so, resulting in extended waits for assistance with basic needs such as toileting, transfers, and obtaining water. Some residents reported having to wait up to an hour for assistance, which caused discomfort and anxiety, especially for those with a history of falls or medical conditions that made waiting particularly difficult. Interviews with residents revealed that these issues were not isolated incidents but occurred frequently and affected multiple individuals. Residents expressed frustration, anxiety, and feelings of being forgotten or unimportant due to the delays and lack of follow-through by staff. The facility's policy required call lights to remain on until the resident's needs were met, but documentation and resident reports indicated that this policy was not consistently followed. Staff training had been initiated to address the issue, but residents continued to report problems with call light response and the manner in which care was provided.
Failure to Follow PPE and Hand Hygiene Protocols for C. diff Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for a resident on Transmission Based Precautions due to Clostridium difficile (C. diff) infection. The resident was admitted with diagnoses including enterocolitis caused by C. diff and end stage renal disease, and had active physician orders for Contact Precautions. Observations revealed that a Physical Therapy Assistant exited the resident's room after removing gown and gloves but used hand sanitizer instead of washing hands with soap and water, contrary to facility policy and CDC guidelines for C. diff. The assistant acknowledged forgetting the correct procedure during an interview. Additionally, a Certified Nursing Assistant entered the same resident's room without performing hand hygiene or donning required PPE, and assisted the resident directly, resulting in contact between her clothing and the resident and his wheelchair. The CNA did not perform hand hygiene after the interaction. Both staff members reported awareness of the correct procedures for C. diff precautions, including the need for soap and water handwashing and use of gown and gloves, but failed to follow them. Facility policies reviewed confirmed these requirements for staff caring for residents on Contact Precautions for C. diff.
Failure to Notify Responsible Parties of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to notify the responsible parties of two residents after an incident involving inappropriate physical contact between residents. According to the facility's own policies, family or responsible parties must be notified of any change in mental, psychosocial, or behavioral management, as well as any alleged violations involving abuse. In this case, a male resident with a history of dementia and behavioral issues was observed grabbing the back of a female resident's head and kissing her. The female resident, who also had dementia and was not her own responsible party, was unable to recall the incident and showed no immediate signs of distress. However, there was no documentation or evidence that her responsible party was notified of the event. Staff interviews and record reviews confirmed that the incident was reported internally to the RN, DON, and NHA, but none of them instructed staff to notify the responsible parties of either resident involved. Text messages reviewed by the LPN and RN indicated that the LPN had asked about notifying the responsible party but was told not to do so. The DON and NHA also confirmed that they did not notify the responsible parties and could not find any documentation that such notification occurred. Additionally, observations revealed that the male resident continued to display inappropriate behaviors, such as making sexual comments and gestures toward other residents and staff, and attempting to grab others. Despite these ongoing behaviors and the initial incident, there was still no indication that the responsible parties for either resident were informed, as required by facility policy. The failure to notify responsible parties of events that may have mental or psychological impact constitutes the deficiency cited in this report.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. According to the facility's abuse policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately to the Administrator or DON, and to appropriate licensing agencies within specified timeframes. On the date in question, an activity aide observed a male resident grab the back of a female resident's head and kiss her. The female resident, who had dementia and was not her own responsible party, was unable to recall the incident and showed no signs of distress. The incident was reported up the chain of command to the RN, DON, and NHA, but no one instructed that it be reported to the State Agency, and no documentation of interviews or further investigation was made. Further review revealed that the male resident involved had a history of dementia, Alzheimer's disease, and behavioral issues, including making sexual comments and gestures toward staff and other residents. Staff interviews confirmed that the incident was witnessed and reported internally, but the DON and NHA decided not to investigate or report the event to the State Agency because there was no intent, injury, or recall of the event by the resident. The only witness, the activity aide, described the incident as a romantic kiss and stated she intervened immediately. The facility did not document any interviews or conversations about the event. Observations also showed that the activity room, where the incident occurred, was at times left unsupervised, with only one staff member present for 12 residents, including the male resident known to require close supervision due to inappropriate behaviors. Despite the facility's policy and the nature of the incident, the required reporting and investigation procedures were not followed, resulting in a failure to notify the State Agency of the alleged abuse.
Failure to Investigate Alleged Abuse Between Residents
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, both with dementia and other significant medical conditions. An incident occurred in which a male resident was observed grabbing the back of a female resident's head and kissing her. The female resident was unable to recall the incident, and no signs of distress or injury were noted at the time. The event was witnessed by an activity aide, who reported it to the nurse in charge when it was safe to do so. The nurse notified the RN, who in turn notified the DON and NHA via text message. However, no formal investigation was initiated, and no documentation of interviews or further inquiry was completed. Staff interviews revealed that the incident was not reported to the State Agency, and the facility leadership decided not to investigate further because there was no apparent intent, injury, or recall of the event by the resident involved. The only witness, the activity aide, was spoken to by phone, but no written records or detailed accounts were maintained. The staff involved did not recall being instructed to investigate or notify additional parties, and there was a lack of clarity regarding who else may have witnessed the event or was present at the time. Additionally, observations showed that the male resident involved had a history of inappropriate touching and sexual comments toward other residents and staff. Despite this behavioral history and the incident in question, the facility did not initiate a timely or thorough investigation as required by their abuse policy. The policy mandates immediate initiation of an investigation and reporting to appropriate authorities, which was not followed in this case.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to accurately document and correlate the Minimum Data Set (MDS) assessment information for a resident, identified as R61, who has a history of behaviors such as hitting himself and displaying aggression towards staff. The resident was admitted with diagnoses of Alzheimer's Disease and Dementia with agitation. The MDS assessment, which is crucial for developing an individualized care plan, did not accurately reflect the resident's behavioral symptoms during the specified observation periods. This inaccuracy could potentially impede the development of a care plan tailored to the resident's needs. During the assessment period from 1/25/24 to 1/31/24, the resident exhibited behaviors such as yelling, spitting, and refusing medications, as documented in the Electronic Medical Record (EMR) progress notes. However, the MDS assessment completed by the Social Services Designee (SSD) I inaccurately recorded that no physical or verbal behaviors were exhibited. This misrepresentation led to the skipping of crucial assessment sections that evaluate the impact of these behaviors on the resident's well-being and environment. Similarly, for the assessment period from 4/12/24 to 4/18/24, the MDS again failed to document the resident's behaviors accurately, despite evidence in the EMR indicating incidents of self-harm and yelling. The SSD I signed off on the MDS assessment without including these behaviors, which were noted in a Social Service Note just minutes before the MDS was finalized. This repeated failure to document accurately raises concerns about the facility's ability to assess residents properly and develop effective care plans.
Failure to Perform Ordered Pressure Ulcer Interventions and Monitoring
Penalty
Summary
The facility failed to perform ordered pressure ulcer interventions and adequately monitor and assess a pressure ulcer for a resident, resulting in the potential for worsening pressure ulcers. The resident, who was admitted with a foot ulcer, a pressure ulcer, and peripheral vascular disease, was cognitively intact with a BIMS score of 13. The care plan required the use of a foam boot while in bed to aid in pressure reduction, but this intervention was not consistently followed. The facility's policy required weekly documentation and pictures of pressure ulcers, but this was not done for the resident's right heel wound since December 2023. Despite physician orders to apply a foam boot while in bed, the resident reported not wearing the boot for months, and staff did not offer it. The Treatment Administration Record inaccurately documented the use of the foam boot, and staff were unable to locate it during observations. Interviews with staff revealed a lack of awareness and documentation regarding the resident's wound care. The LPN admitted to documenting the foam boot use in error, and the DON confirmed the absence of weekly wound measurements or pictures. The wound nurse practitioner confirmed the wound was still open and had never completely healed, contradicting the facility's records.
Failure to Document Physician Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician reviewed a pharmacy recommendation for a resident, identified as R61, who was receiving both Mobic, a non-steroidal anti-inflammatory drug (NSAID), and Eliquis, an anticoagulant. The pharmacy recommendation, dated 12/7/23, highlighted the potential serious side effects of combining these medications, including increased cardiovascular and gastrointestinal risks. Despite this, there was no documentation in the resident's electronic medical record (EMR) indicating that the physician, MD G, or any physician designee, had conducted a benefit/risk analysis or was aware of the pharmacy's recommendation. The Director of Nursing (DON) confirmed during interviews that the benefit/risk analysis should have been documented in the resident's EMR but could not be found. The DON stated that the Clinical Care Coordinator (CCC) F, a registered nurse, had entered a follow-up note on 12/12/23, indicating that the current therapy's benefits outweighed the risks, but this was not supported by any documentation from MD G. The facility's policy required that if a prescriber did not respond to a pharmacy recommendation within 30 days, the DON and/or consultant pharmacist should contact the Medical Director, but there was no evidence that this had occurred. The lack of documentation and follow-up on the pharmacy recommendation resulted in the potential for the physician not being aware of the serious side effects associated with the combined use of Mobic and Eliquis. This oversight could have significant implications for the resident's health, given their medical history, which includes conditions such as chronic atrial fibrillation, hypertension, and a history of stroke. The facility's failure to ensure proper communication and documentation of the pharmacy's recommendation represents a deficiency in their medication management process.
Failure to Evaluate Medication Risks for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically concerning the concurrent use of Mobic and Eliquis. The resident, who was admitted with multiple diagnoses including right hip pain, chronic atrial fibrillation, hypertension, and a history of transient ischemic attack and cerebral infarction, was receiving Mobic, a non-steroidal anti-inflammatory drug, and Eliquis, an anticoagulant. A pharmacy recommendation highlighted the potential risks associated with this combination, including increased cardiovascular and gastrointestinal risks, and advised a benefit/risk analysis. However, the facility did not document any such analysis or physician's note addressing the pharmacist's recommendation. Despite the pharmacist's warning, the resident continued to receive both medications for approximately 6.5 months without documented evaluation by the medical director or any physician designee. The Director of Nursing confirmed the absence of a benefit/risk analysis or any physician's note in the resident's electronic medical record. This lack of documentation and evaluation resulted in the potential for the resident to have received unnecessary medications over an extended period, as the facility did not provide evidence of addressing the identified potential problem.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential miscommunication and an unclear picture of the residents' healthcare status. For Resident #33, the deficiency involved the incorrect documentation of the use of a foam protective boot. The resident was admitted with diagnoses including a foot ulcer and peripheral vascular disease, and the care plan required the use of a foam boot while in bed. However, the boot was not found in the resident's room, and an LPN admitted to documenting its use in error, as the resident had been wearing a post-op shoe instead. For Resident #61, the deficiency involved the lack of documentation regarding a benefit/risk analysis for the concurrent use of Mobic and Eliquis, as recommended by the pharmacy. The resident had multiple diagnoses, including right hip pain and chronic atrial fibrillation, and was at risk for cardiovascular and gastrointestinal events due to the medication combination. Despite the pharmacy's recommendation, there was no documentation in the electronic medical record indicating that the physician had conducted the necessary analysis or addressed the concurrent medication use. The Director of Nursing confirmed the absence of the required documentation for Resident #61, acknowledging that the benefit/risk analysis was not present in the resident's electronic medical record. This lack of documentation was contrary to the facility's policy and the American Nursing Association's principles for nursing documentation, which emphasize the importance of clear, accurate, and accessible records to ensure informed decisions and high-quality care.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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