South Haven Nursing And Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in South Haven, Michigan.
- Location
- 850 Phillips, South Haven, Michigan 49090
- CMS Provider Number
- 235270
- Inspections on file
- 28
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 36 (1 serious)
Citation history
Health deficiencies cited at South Haven Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed, despite being identified as an elopement risk. Staff were aware of the resident's patterns, such as checking doors and expressing a desire to leave, but there was no individualized documentation or consistent monitoring of these behaviors prior to the incident. The resident was found walking along a busy road by a staff member and returned to the facility.
Two residents with severe cognitive impairment and a history of exit-seeking behaviors were not provided with individualized care plans. Instead, generic interventions were used, and specific behaviors such as fixation on cars and cigarettes were not addressed. One resident was able to leave the facility unsupervised, and staff interviews revealed a lack of documentation and monitoring for escalating behaviors, with care plans relying on non-individualized templates.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager to oversee nutritional services. The Dietary Supervisor, in the role for two years, is not yet certified but is taking classes. A dietitian visits only a couple of times a week, increasing the risk of food service sanitation failures and inadequate assessment of high-risk residents.
A long-term care facility was found to have multiple deficiencies in food safety and sanitation during a survey. The kitchen had issues with unlabeled and undated food items, dirty equipment, and improper storage practices. The walk-in cooler and dry storage areas contained items without proper labeling, and the kitchen equipment was not maintained in a clean condition. Additionally, the refrigeration unit in the resident area was at an unsafe temperature, posing a risk of foodborne illness.
The facility failed to maintain an effective water management plan and infection control program. The Maintenance Director was unsure of control measures beyond routine flushing and had not conducted water testing. The Infection Preventionist missed resident vaccinations, lacked a tracking process, and failed to ensure staff training on infection control. The infection control log was incomplete, and there was no clear responsibility for infection monitoring, indicating deficiencies in both programs.
A facility failed to implement an antibiotic stewardship program and monitor antibiotic use for a resident. The Infection Preventionist (IP) did not assess antibiotic use according to Mcgeer's criteria and lacked documentation on antibiotic indications, dosages, or durations. The IP also did not follow up on outcomes or provide feedback on antibiotic use, relying on nursing staff documentation. The Director of Nursing (DON) did not oversee the stewardship program, leaving all responsibilities to the IP, resulting in potential inappropriate antibiotic use and resistance.
The facility failed to maintain cleanliness and repair, affecting resident rooms and common areas. Observations revealed dust and debris in rooms, stained ceiling tiles, and disrepair in utility spaces. Residents with chronic obstructive pulmonary disease were exposed to dusty fans, and one resident had to clean her own bathroom due to dissatisfaction with housekeeping. Damaged and dirty wheelchairs were also noted, with inconsistencies in cleaning schedules and maintenance awareness.
A resident with cognitive impairment and physical limitations was repeatedly found with the call light out of reach, preventing them from calling for assistance. Despite the care plan's directive to keep the call light accessible, observations showed it was often on the floor or under the bed.
A facility failed to create a comprehensive care plan for a resident on Eliquis, an anticoagulant prescribed for deep vein thrombosis. Despite the resident's diagnoses of congestive heart failure and hypertension, no care plan was in place to address the potential side effects of the medication. The MDS Coordinator and DON both acknowledged the oversight, emphasizing the importance of care plans for high-risk medications.
A facility failed to implement care plan interventions for a resident with muscle contracture, as the resident was observed not wearing prescribed splints on multiple occasions. Despite occupational therapy recommendations and care plan documentation, staff interviews revealed a lack of awareness and adherence to the care plan, leading to the potential for worsening contractures.
A resident with dementia and a history of falls experienced a fall resulting in facial injuries due to inadequate supervision and failure to implement safety interventions. The resident, who self-ambulated in a wheelchair, fell near a chapel ramp without caution signs, despite this being part of her care plan. Observations showed the resident was often left unattended, and staff admitted to not applying necessary safety measures.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for a resident's antidepressant and antipsychotic medications, potentially leading to unnecessary dosing. The resident, with a diagnosis of unspecified mood affective disorder, was prescribed Olanzapine and Sertaline. Despite the care plan indicating a need for dose reduction, there was no documentation of GDR attempts or justification for not attempting one. Interviews revealed a lack of awareness and documentation regarding GDR attempts, with reliance on a local mental health provider without evidence of collaboration or follow-up visits.
A resident with diabetes received an incorrect dose of insulin due to a new nurse's error, leading to a significant drop in blood sugar levels. The nurse, who was still in orientation, administered 32 units of short-acting insulin instead of the prescribed doses, causing the resident to experience severe symptoms and miss a dialysis appointment. The error was reported and investigated by the facility's staff.
A facility failed to administer a pneumococcal vaccine to a resident with chronic obstructive pulmonary disease, despite consent from the guardian and the resident being due for the vaccine. The Infection Preventionist acknowledged the oversight, citing staff turnover and a backlog in the vaccine program as contributing factors.
A facility failed to offer a COVID-19 vaccination to a resident with chronic obstructive pulmonary disease, as there was no record of vaccination in their Electronic Health Record. The Infection Preventionist admitted to not screening or offering the vaccine to the resident and lacked a systematic approach to ensure staff were educated and offered the vaccine, relying only on posted signs during clinics.
The facility failed to ensure timely care and services for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth. One resident reported waiting up to two hours for assistance, while another's family member noted frequent delays and clutter. A third resident in extreme pain also experienced delays in receiving care.
A resident with cognitive impairments reported being punched by a CNA after using racial slurs. The facility's investigation revealed inconsistencies in staff and resident accounts, and the incident was not adequately documented. The deficiency highlights a lapse in protecting the resident from potential abuse and the need for improved adherence to abuse prevention policies.
The facility failed to ensure physician orders for scheduled pain medications were in place and did not accurately document the administration of controlled medications for a resident with terminal cancer. This resulted in inadequate pain management and potential drug diversion.
The facility failed to maintain safe infection control practices for a resident on Enhanced Barrier Precautions due to chronic wounds and a Foley catheter. Staff were observed handling the resident's catheter bag and transferring the resident without wearing the required PPE, and there was a lack of hand hygiene and PPE availability, leading to potential cross-contamination.
Failure to Limit PRN Psychotropic Medication to 14 Days Without Provider Rationale
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications for a resident included a stop date not exceeding 14 days, as required. A male resident with diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed hydroxyzine, an antihistamine also used for anxiety, on a PRN basis. The medication orders were written with start and discontinue dates that exceeded the 14-day limit for PRN psychotropic medications, and there was no documentation of a provider rationale to justify extending the use beyond this period. During an interview, the Director of Nursing (DON) confirmed that PRN psychotropic medications should be limited to 14 days unless a provider documents a rationale for extension. Review of the resident's orders showed that the required 14-day stop dates were not implemented for both instances of the hydroxyzine prescription, and no provider rationale for the extended use was provided by the time of the survey exit.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including unspecified dementia, unspecified mood disorder, unsteadiness on feet, and required assistance with personal care, was severely cognitively impaired as indicated by a BIMS score of 3/15. Despite being identified as an elopement risk and having a care plan that included interventions such as alarms and monitoring, the resident was able to leave the facility premises unnoticed by staff. The resident was last seen by staff approximately 15 minutes before being found outside the facility, walking along a road without a sidewalk, by a staff member who happened to be driving by. Multiple staff interviews revealed that the resident had a known pattern of exit-seeking behaviors, including frequently checking doors, setting off alarms, and expressing a desire to leave the facility for cigarettes or to see white cars. Staff also reported that the resident's behaviors would escalate, but there was no documentation or consistent monitoring of these behaviors in the resident's medical record prior to the elopement event. Although the facility had a blanket behavior monitoring order for all residents, it was not individualized or specific to the resident's known behaviors. Communication about the resident's increased exit-seeking behaviors was primarily verbal and not consistently documented or shared with all staff. There was no evidence of behavior logs or specific interventions being implemented or documented in response to the resident's escalating behaviors prior to the incident, which contributed to the failure to prevent the elopement.
Failure to Individualize Care Plans for Residents at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with severe cognitive impairment and a history of exit-seeking behaviors. For one male resident with dementia and a BIMS score indicating severe cognitive impairment, the care plan included generic interventions such as door alarms, quarterly elopement assessments, and offering distractions. However, the care plan did not address the resident's specific behaviors, such as his fixation on white cars and cigarettes, or his pattern of looking out windows and attempting to exit the building. Multiple staff interviews confirmed that the resident routinely checked doors, set off alarms, and expressed a desire to leave the facility for cigarettes or to return home, but these behaviors were not specifically documented or communicated in his care plan. On one occasion, this resident was able to leave the facility unsupervised and was found walking alone along a road by a staff member, who then returned him to the facility. Staff interviews revealed that while staff were aware of the resident's exit-seeking tendencies and specific interests, such as white cars and cigarettes, this information was not consistently documented or included in the care plan. The Director of Nursing and other staff acknowledged that care plans were not individualized and that there was no system in place to monitor or document escalating behaviors that could lead to elopement. A second female resident with dementia and severe cognitive impairment was also identified as an elopement risk, with a history of looking for family and attempting to leave the facility. Her care plan similarly relied on template interventions and did not include specific, individualized strategies to address her behaviors. Staff interviews indicated a lack of awareness and monitoring for elopement risk, and the care plan was not customized to reflect the resident's unique needs or patterns of behavior. The facility's practice of using pre-selected, non-individualized care plan templates contributed to the failure to adequately address and manage the elopement risks for both residents.
Lack of Full-Time Dietitian or Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, the Dietary Supervisor (DS) revealed that the facility only has a dietitian who visits a couple of times a week. The DS, who has been in the role for about two years, is not yet a Certified Dietary Manager but is currently taking classes to become one. She mentioned that it has been challenging to fit the classes into her schedule, and she is seeking an extension to complete them. This deficiency increases the potential for food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents among all residents.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed during a kitchen tour. The kitchen was found to have multiple areas of concern, including a dishwasher area with spilled powdered detergent and discoloration from dripping water. The dish area had a leaking three-compartment sink with a container to catch leaks, and a bucket of liquid detergent covered with dirt and debris. The kitchen prep area had clean utensil drawers with crumbs and debris, cracked spatulas, and equipment with excess buildup and dried food debris. The walk-in cooler contained several items without labeling or dating, such as raw onion, butter, creamed corn, and various other food items. The dry storage area also had unlabeled and undated items, including dry cereal, quick oats, and various mixes. The facility's failure to properly label and date food items, as well as maintain cleanliness and organization in storage areas, poses a risk of foodborne illness among residents. Additionally, the facility's equipment and surfaces were not maintained in a clean and sanitary condition. The can opener, microwave, and ice machine area had significant dirt and debris accumulation. The dish machine area had a cross-connection that could contaminate the potable water supply, and the refrigeration unit in the Bunny Patch resident area was found to be at an unsafe temperature. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code, which outlines necessary standards for food safety and equipment maintenance.
Deficiencies in Water Management and Infection Control Programs
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview, the Maintenance Director was unable to specify control measures beyond routine flushing of domestic fixtures and admitted to not conducting water testing due to waiting on a tester. Additionally, the water line in the family room was not being flushed. The Water Management Plan had not been reviewed with the administrator, and the facility's Water Pathogen Risk Reduction document lacked a date, indicating a lack of comprehensive implementation and documentation. The facility's infection control program was found to be ineffective, as the Infection Preventionist (IP) reported missing resident vaccinations and lacking a thorough tracking process. The IP was unable to confirm staff training on cleaning and disinfecting reusable medical equipment and environmental cleaning. The IP also failed to provide examples of infection control education for staff and could not explain how infection control audits were conducted or tracked. The facility's infection control policies and procedures were not regularly reviewed or updated, and there was no clear process for tracking employee illness or early detection of potential infectious residents. The IP's infection control log for September 2024 was incomplete, only tracking residents prescribed antibiotics, and lacked detailed information on symptoms, diagnosis, and monitoring. The IP relied on nursing staff for infection monitoring and did not ensure all staff received necessary education. The Director of Nursing (DON) reported that the IP was responsible for the infection control program, but the IP was still being assisted by the DON, indicating a lack of clear responsibility and oversight in the infection control program.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as to monitor the appropriate use of antibiotics for a resident. The deficiency was identified during a review of the records and an interview with the Infection Preventionist (IP) C, who was responsible for ensuring that Mcgeer's criteria were used when prescribing antibiotics. However, IP C admitted to missing the assessment of antibiotic use for a resident who had been on antibiotics in September 2024. Furthermore, IP C was unable to provide a list of residents on antibiotics or documentation regarding the indication, dosage, or duration of antibiotic use. Additionally, IP C did not follow up on the outcomes of residents prescribed antibiotics, relying instead on nursing staff documentation. There was no established process for providing feedback on antibiotic use, resistance patterns, or prescribing practices. IP C, being new to the position, was still receiving assistance from the Director of Nursing (DON) B, who reported not overseeing or monitoring the facility's antibiotic stewardship, leaving all responsibilities to IP C. This lack of oversight and documentation resulted in the potential for inappropriate antibiotic utilization and resistance.
Facility Fails to Maintain Cleanliness and Repair
Penalty
Summary
The facility failed to maintain cleanliness and repair in several areas, affecting both resident rooms and common utility spaces. Observations revealed dust and debris accumulation in resident rooms, with specific issues such as stained ceiling tiles indicating possible roof leaks. Shared bathrooms were found with dirt accumulations, and utility rooms had cabinets in disrepair, making them difficult to clean. Additionally, a janitor's closet had a leaking hot water valve and an unlabeled spray bottle, while the central supply room was missing a light shield. Residents were directly impacted by these deficiencies. For instance, two residents with chronic obstructive pulmonary disease were exposed to dusty fans blowing directly towards them, which were not cleaned regularly as per the facility's protocol. Another resident expressed concerns about the cleanliness of her shared bathroom, which was often found with feces on the floor and toilet, despite being cleaned by housekeeping. The resident resorted to cleaning the bathroom herself due to dissatisfaction with the facility's cleaning efforts. Further issues included damaged and dirty wheelchairs, with exposed foam on arm covers and dirt on the wheels and frames. Housekeeping and maintenance staff interviews revealed inconsistencies in cleaning schedules and a lack of awareness about certain deficiencies, such as missing window screens and cracked walls. These observations highlight a systemic issue in maintaining a clean and safe environment for residents, staff, and visitors.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance. The resident, who was moderately cognitively impaired with a history of cerebrovascular accident and left-sided weakness, was observed multiple times with the call light out of reach. On one occasion, the call light was on the floor, and on another, it was under the bed, both times making it inaccessible to the resident. The resident reported using the call light to request help but sometimes could not find it. A Certified Nursing Assistant confirmed that the resident used the call light to ask for assistance. Despite the care plan specifying that the call light should be within reach, observations over several days showed that this was not consistently ensured, leading to potential unmet care needs.
Failure to Implement Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anticoagulant medication, Eliquis, for a history of deep vein thrombosis. The resident, a female with diagnoses of congestive heart failure and hypertension, did not have a care plan that addressed her anticoagulant therapy, which is crucial due to the potential side effects such as heavy bruising. The MDS Coordinator, responsible for creating care plans for high-risk medications, acknowledged the absence of a care plan for the resident's anticoagulant therapy during an interview and record review. The Director of Nursing also confirmed that care plans should be in place for high-risk medications to ensure staff are aware of and monitor potential side effects.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident with a diagnosis of muscle contracture. The resident was admitted with pertinent diagnoses, including contracture of muscles, and had been discharged from occupational therapy with specific recommendations for wearing a right hand T bar splint and a left upper extremity hand roll or gauze during the day as tolerated. These recommendations were documented in the resident's care plan, which specified the use of these assistive devices during morning care and their removal at lunch or as tolerated. Observations on multiple occasions revealed that the resident was not wearing the prescribed splints on the right hand, left hand, or elbow while sitting in a wheelchair in the dining room or lying in bed. Interviews with facility staff, including a Physical Therapy Assistant and a Certified Nursing Assistant, confirmed that the expectation was for the CNAs to place the splints on the resident during morning care. However, the CNA reported being unaware of the requirement for the resident to wear the splints during the day, indicating a lapse in communication or adherence to the care plan, leading to the potential for worsening of the resident's contractures.
Failure to Implement Safety Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and implement necessary safety interventions for a resident, identified as R15, who was at high risk for falls due to cognitive impairment and a history of falls. R15, who had dementia and was able to self-ambulate in a wheelchair, experienced a fall resulting in facial bruising and a laceration that required sutures. The fall occurred when R15 was self-ambulating near the chapel, an area with a ramp that posed a hazard, and there were no yellow caution signs or strips in place to warn of the descent, despite this being an intervention listed in the resident's care plan. The resident's care plan, which identified her as at risk for falls due to dementia, altered mental status, and limited mobility, included interventions such as keeping her in high traffic areas and applying yellow caution strips at the start of the ramp to the chapel. However, these interventions were not consistently implemented. Observations revealed that R15 was often left unattended in her wheelchair, both in the dining room and near the nursing station, where she attempted to self-ambulate, leading to her legs becoming tangled in the wheelchair's foot pedals. Interviews with staff and family members highlighted concerns about the lack of supervision and the failure to implement safety measures. Family members questioned why R15 was left unsupervised, and staff acknowledged that the resident was known to self-ambulate throughout the facility. The Director of Nursing admitted that the yellow caution strips were never applied, despite being part of the care plan, and the resident continued to be at risk for falls due to inadequate supervision and environmental hazards.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for a resident, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time. The resident was admitted with diagnoses including unspecified mood affective disorder and was prescribed Olanzapine and Sertaline. The care plan indicated a need for dose reduction, but there was no documentation of any attempts for GDRs or justification for not attempting a GDR since October 2023. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed a lack of awareness and documentation regarding the resident's GDR attempts. The DON could not report the last GDR attempt or any clinical indication for not attempting a GDR. The SW indicated reliance on a local mental health provider for managing the resident's psychotropic medications, but there was no evidence of collaboration or follow-up visits for nearly a year. The facility was unable to provide documentation justifying the absence of GDR attempts prior to the survey exit.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. A resident, who was cognitively intact and had a diagnosis of diabetes, reported receiving an incorrect dose of insulin. The error occurred when a new nurse, who was still in her orientation period, administered 32 units of short-acting insulin instead of the prescribed 2 units of short-acting and 30 units of long-acting insulin. This mistake was attributed to the nurse being nervous and in a rush, leading her to not verify the correct type of insulin before administration. As a result of the medication error, the resident experienced a significant drop in blood sugar levels, leading to symptoms such as fatigue, inability to keep her eyes open, and verbal non-responsiveness. The resident's blood sugar dropped to 54, prompting immediate intervention with carbohydrates and milk to stabilize her condition. The error also caused the resident to miss a dialysis appointment. The incident was reported by the physical therapist and investigated by the Director of Nursing, who confirmed the error and provided education to the nurse involved.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive pneumococcal vaccinations, specifically for one resident among those reviewed. Resident #22, who was admitted with chronic obstructive pulmonary disease, had a consent form signed by their guardian indicating a willingness to receive the pneumococcal vaccine, provided it had been more than three years since the last dose. The Michigan Care Improvement Registry showed that Resident #22 was due for a pneumococcal vaccine on 9/7/22, but this was not administered. During an interview, the Infection Preventionist (IP C) confirmed responsibility for screening and administering vaccines and acknowledged that Resident #22 was due for an updated pneumococcal vaccine. However, IP C could not explain why the vaccine had not been administered, attributing the oversight to the facility's vaccine program being behind schedule due to staff turnover and her recent assumption of the IP position in March 2024. This lapse resulted in the potential risk of acquiring or transmitting pneumococcal pneumonia.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident, leading to a deficiency in their vaccination protocol. Resident #51, who was admitted with chronic obstructive pulmonary disease, did not have any record of receiving a COVID-19 vaccination in their Electronic Health Record. Although a Vaccine Consent Form indicated that the resident had previously received a COVID-19 vaccination, it did not specify if additional doses were desired. During an interview, the Infection Preventionist (IP) admitted to not having offered the COVID-19 vaccine to Resident #51 and acknowledged a lapse in tracking and offering vaccinations to both residents and staff. The IP also reported that there was no systematic approach to ensure staff were screened, educated, and offered the vaccine annually, relying instead on posting signs during clinics without further follow-up.
Failure to Ensure Timely Care and Services
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth, sadness, and frustration. Resident #200, who was cognitively intact, reported waiting up to two hours for assistance with repositioning and an hour for help with changing and getting ready for bed. The Director of Nursing and Unit Manager were unaware of any staffing issues that could explain the delays, and the facility lacked a specific policy or timeframe for responding to call lights. Resident #201's family member reported that the resident often had to wait up to an hour for call lights to be answered and was frequently found lying in bed with food on him and in a soiled brief. The room was observed to be cluttered with various items. Resident #202, who was in extreme pain from terminal cancer, also experienced delays in receiving pain medication and toileting assistance, with staff appearing bothered when asked for help. Observations of the nurses' station revealed outdated and incomplete information on a dry erase board, further indicating a lack of attention to detail and resident care needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #201, who was moderately cognitively impaired and had a history of stroke, weakness, depression, anxiety, and dementia, reported being punched by a CNA. The incident was initially reported by a hospice worker who observed a bruise on the resident's right upper arm. The facility's Director of Nursing (DON) confirmed the presence of the bruise but did not document it with measurements or photographs. The resident admitted to using racial slurs towards the CNA, which led to the alleged physical altercation. Multiple staff members, including the CNA involved, reported that the resident had been combative during care, but other staff and family members noted that the resident was typically pleasant and non-combative. The facility's investigation included interviews with the resident, staff, and family members, but there were inconsistencies in the accounts of the resident's behavior and the events leading to the bruise. The facility's abuse prevention policy explicitly states that striking a combative resident is not an appropriate response, yet the investigation did not conclusively determine whether the CNA's actions constituted abuse. The care plan for the resident was updated after the incident to address his behavioral symptoms, including negative racial statements and combativeness during care. However, the facility's failure to adequately document and investigate the incident, as well as the conflicting reports from staff and the resident, indicate a deficiency in protecting the resident from potential abuse. The facility's policy on abuse prevention emphasizes the importance of professional behavior and the safety and well-being of residents, but the handling of this incident suggests a lapse in adherence to these standards. The deficiency highlights the need for more thorough documentation and consistent application of abuse prevention protocols to ensure resident safety. The facility's response to the incident, including the lack of immediate documentation and the delayed care plan update, underscores the importance of timely and accurate reporting in abuse investigations. The conflicting accounts from staff and the resident further complicate the investigation, making it difficult to determine the exact nature of the incident and whether the resident's rights were adequately protected. The facility's failure to protect the resident from potential abuse and the inconsistencies in the investigation process indicate a need for improved training and adherence to abuse prevention policies. The incident underscores the importance of maintaining a safe and respectful environment for all residents, particularly those with cognitive impairments and behavioral challenges. The facility must take steps to ensure that all staff are trained in appropriate responses to combative behavior and that incidents of potential abuse are thoroughly documented and investigated. The deficiency in this case highlights the need for ongoing monitoring and quality improvement efforts to protect residents from harm and uphold their rights to a safe and dignified living environment.
Failure to Implement Physician Orders and Document Controlled Medications
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring physician orders were in place for scheduled pain medications and not accurately documenting the administration of controlled medications for a resident with terminal cancer. The resident, who was in extreme pain, had a physician's order to change his narcotic pain medication from PRN (as needed) to a scheduled dose. However, this change was not implemented until days later, resulting in the resident receiving inadequate pain management during his stay at the facility. The resident's family member reported that the call light for pain medication often went unanswered, and the resident was eventually transferred to a hospital where he passed away shortly after. The Director of Nursing (DON) confirmed that new orders should go into effect immediately and acknowledged past issues with the physician responsible for the resident's care. Additionally, the controlled substance sign-out sheets revealed that the resident received multiple doses of pain medication that were not recorded in the Medication Administration Record (MAR), indicating a failure in proper documentation and potential drug diversion. Interviews with the facility staff, including the DON, Unit Manager (UM), and Assistant Director of Nursing (ADON), revealed confusion and lack of documentation regarding the resident's pain medication orders. The ADON could not recall why the medication order was changed days after the physician's visit, and the DON confirmed that the doses of pain medication administered were not recorded in the MAR. This lack of accurate documentation and timely implementation of physician orders led to the resident experiencing unmanaged pain and highlighted significant deficiencies in the facility's medication management and documentation practices.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain safe infection control practices for Resident #200, who was on Enhanced Barrier Precautions (EBP) due to chronic macerated wounds and a Foley catheter. During an observation, a CNA and an LPN were seen handling the resident's catheter bag and transferring the resident without wearing the required PPE, such as gowns and goggles. Additionally, the CNA did not perform hand hygiene after removing gloves, and there was no PPE cart in sight. The resident had multiple superficial open wounds on his thighs that were not adequately covered by dressings, and the staff continued to handle the resident and his equipment without changing gloves or donning additional PPE, even when the resident had a bowel movement and required assistance with a bedpan. Interviews with staff revealed a lack of awareness and adherence to the EBP requirements. One CNA was unaware of the reason for the EBP and noted that gowns were not available in the resident's room. The Director of Nursing confirmed that staff should wear gowns, gloves, and goggles when providing direct care to Resident #200, especially when managing his catheter bag. The failure to follow proper infection control protocols resulted in the potential for cross-contamination and the spread of multi-drug resistant bacteria.
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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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