Stratford Pines Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Midland, Michigan.
- Location
- 2121 Rockwell Drive, Midland, Michigan 48642
- CMS Provider Number
- 235608
- Inspections on file
- 20
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Stratford Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with dementia and mobility impairments experienced repeated falls and unsafe transfers due to lack of adequate supervision, assistance, and individualized interventions. Staff failed to provide necessary help during critical moments, and care plans were not effectively implemented or updated to address the root causes of falls, resulting in ongoing safety hazards.
Two residents' concerns regarding meal preferences, food quality, and ambulation assistance were not addressed in a timely manner. One resident with significant medical needs and weight loss experienced ongoing dissatisfaction with meals and lack of dietary accommodations, while another resident and her family requested ambulation support that was denied without documented justification. In both cases, staff failed to document or communicate the grievances, and residents were not informed about the grievance process.
A resident with cognitive and mobility impairments was found with a shifted specialty mattress, exposing the metal bed frame and creating a gap between the mattress and bed rail that exceeded regulatory limits. The facility's documentation and assessment of bed rail and mattress safety were incomplete, lacking required measurements and ongoing monitoring for entrapment risk.
The facility failed to ensure the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards, and did not have required records of system acceptance, maintenance, and testing readily available.
Two residents in an LTC facility experienced multiple unwitnessed falls due to inadequate supervision and failure to implement effective care plan interventions. Despite having conditions like Alzheimer's, Parkinson's, and orthostatic hypotension, the facility did not conduct necessary post-fall neurological assessments or tailor care plans to address specific fall risk factors. The Director of Nursing acknowledged documentation and supervision deficiencies but did not provide additional information to address the concerns.
The facility's kitchen had several deficiencies, including missing handwashing signage, undated water filters, and improper drainage causing standing water. The kitchen's coving was removed, making surfaces difficult to clean, and a wall required repair due to visible joists. These issues contravene FDA 2017 Food Code requirements for maintaining physical facilities and equipment.
A facility failed to inform the designated medical DPOAs of a resident about the use of psychoactive medications, instead notifying the financial DPOA. The resident, unable to make medical decisions, had designated DPOA R and DPOA S for medical decisions, but the facility lacked their contact information and continued to rely on DPOA Q for medical decisions. The DON confirmed the oversight, acknowledging the absence of documentation involving the correct DPOAs in medical decision-making.
A facility failed to conduct a timely care conference for a resident with a history of stroke, dementia, and depression, resulting in the potential for the resident and/or their responsible party not participating in their person-centered plan of care. Despite the requirement for care conferences every three months, no conferences were scheduled after the initial one, even after the resident was deemed unable to make medical decisions. The Social Services Director cited an upcoming guardianship court date as a reason for the delay.
A facility failed to notify the correct medical DPOA of a resident's treatment preferences, contacting a financial DPOA instead. The resident, unable to make medical decisions due to cognitive impairments, had designated DPOA R and DPOA S for medical decisions, but the facility lacked their contact information. The DON confirmed the oversight and the absence of documentation regarding communication with the appropriate DPOA.
A facility failed to implement a comprehensive care plan for a resident with Multiple Sclerosis and other conditions, lacking personalized and measurable interventions to achieve her goals of weight loss and strength improvement. Despite being cognitively intact, the care plan only included general interventions, and staff interviews revealed insufficient efforts to assist the resident. The resident confirmed that no daily ROM exercises were performed with her.
A resident with a suprapubic catheter experienced issues with the catheter becoming plugged and leaking, which were not promptly addressed by the facility. An LPN changed the gauze at the insertion site without proper assessment, and facility records lacked documentation of the wound or consistent catheter care. Despite communication with a Nurse Practitioner, the electronic medical record did not reflect new assessments or orders for wound care.
A facility failed to provide restorative care and ROM interventions for a resident with quadriplegia and rheumatoid arthritis. The resident was often without prescribed finger flexion gloves, and there was a lack of documentation regarding their use and any PROM services. Despite instructions for the gloves to be worn twice daily, they were not consistently applied, and refusals were not documented or addressed.
A facility failed to provide necessary respiratory care for a resident with COPD who is dependent on supplemental oxygen. The resident reported that staff sometimes did not apply her BiPAP machine at night. Observations confirmed the absence of active orders and documentation for the BiPAP machine in the EMR, despite its necessity being noted in the care plan and progress notes. The DON acknowledged the oversight, noting that orders were not restarted after the resident's hospital return.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis care. The resident, with diabetes and kidney disease, was dependent on hemodialysis thrice weekly. Despite a care plan requiring communication with the dialysis center and post-dialysis monitoring, these protocols were not followed. LPN C reported no communication paperwork was exchanged, and dialysis forms in the EMR were not reviewed by clinical staff. Additionally, post-dialysis assessments were not conducted as required, with LPN C not obtaining new vital signs upon the resident's return from dialysis.
The facility failed to properly label medications, including a Breo-Elipta discus and a TB PPD vial, in a medication cart and room. The discus was not labeled with the resident's name or room number, and the TB vial lacked an open date. Staff showed inconsistency in understanding labeling requirements, with the DON confirming the need for labeling but unsure of TB vial usage duration.
The facility failed to maintain accurate medical records for three residents, with care conferences not documented in the EMR as required. The Social Services Director admitted to not entering notes for scheduled conferences, leading to discrepancies in the records. This lack of timely and accurate documentation contravenes facility policy and nursing principles.
A facility failed to implement effective infection control interventions and conduct a root cause analysis for a resident with recurrent UTIs. Despite the resident's history of UTIs and positive urinalysis results showing E. coli, the facility did not identify trends or add new interventions to prevent infections. The resident was repeatedly started on antibiotics before culture results were available, leading to changes in medication once results were received. The Infection Preventionist acknowledged the resident's resistance to care but did not provide comments on the origins of E. coli or preventative measures.
A resident with a history of fractures and cognitive issues was admitted to a facility and did not receive prescribed pain medication for over two days. Despite being at risk for falls, the facility failed to implement increased supervision or safety measures. The resident fell, sustaining spinal fractures, and later died from injuries related to the fall.
Failure to Provide Adequate Supervision and Fall Prevention for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate supervision, assistance, and meaningful interventions to prevent falls for two residents with dementia and mobility impairments. One resident experienced multiple unwitnessed falls over a period of several months, often while attempting to ambulate or transfer without assistance. Incident reports revealed that interventions were either repeated without modification, not implemented as planned, or not tailored to the root causes of the falls, such as confusion, non-compliance with call light use, and changes in room location. The care plan lacked specific strategies to ensure supervision during waking hours, and staff were not always aware of the resident's routines or needs for observation. Another resident, also with dementia and mobility issues, was observed leaving the dining room unassisted, attempting to access the restroom without staff help, and transferring unsafely from a wheelchair to a chair without locking the brakes. Staff present in the area did not provide assistance or seek help for the resident, and the unsafe transfer was not witnessed by facility staff. The resident's care plan indicated a need for staff assistance with transfers and toileting, but these interventions were not followed during the observed events. Interviews with the DON confirmed that investigations into falls did not consistently identify root causes or result in new or effective interventions. The DON was unable to provide information on how the facility would ensure adequate supervision and assistance for residents with dementia and high fall risk. The lack of meaningful, individualized interventions and failure to provide supervision and assistance directly contributed to repeated falls and unsafe situations for these residents.
Failure to Respond Timely to Resident Grievances and Preferences
Penalty
Summary
The facility failed to respond in a timely manner to resident concerns for two residents regarding food preferences, meal quality, and ambulation assistance. One resident, who had a history of traumatic brain injury, cognitive communication deficit, and cancer with significant weight loss, reported ongoing dissatisfaction with the meals provided, including issues with food type, temperature, and lack of dietary accommodations. The resident and his wife stated they had complained almost daily since admission but were unaware of how to file a formal concern. The dietary manager was not aware of the resident's food preferences, and the required paperwork was found incomplete in the resident's room. Additionally, requests to eat in the dining room and be out of bed for meals were not communicated to the care staff, and no concern forms were completed or provided for these ongoing complaints. Another resident with dementia, depression, and mobility difficulties requested, along with her family, to be walked to the bathroom daily instead of being transported in a wheelchair. Although the care plan indicated she required only one-person assistance with a walker and therapy notes confirmed her ability to ambulate with minimal help, the facility denied the request, citing safety concerns without documented justification. The DON was unable to locate any risk/benefit analysis or documentation supporting the decision to refuse the resident's request, nor were any concern forms found to address the resident's or family's repeated concerns. In both cases, the facility did not provide evidence of a timely or effective response to resident grievances, failed to document or communicate resident preferences and concerns, and did not ensure that residents and their families were informed about the grievance process. These actions resulted in the residents' needs and preferences not being addressed as required by facility policy.
Failure to Assess and Maintain Bed Rail and Mattress Safety
Penalty
Summary
The facility failed to ensure proper assessment and maintenance of bed rails and mattresses for one resident reviewed for accident hazards. The resident in question had a history of traumatic brain injury, cognitive communication deficit, difficulty walking, and general weakness. Upon observation, the resident was found sitting at the edge of his bed with the mattress shifted, exposing six inches of the metal bed frame. The mattress, which was a specialty air mattress, was easily compressed and slid with minimal effort, creating a gap of five inches between the mattress and the bed rail while the resident was in a sitting position. The resident had visible bruises and a dressing on his leg, and he was unable to recall the cause of his injuries due to short-term memory loss. No staff were present in the room during the observation. Interviews with facility staff revealed that the maintenance director kept bed safety assessment forms in his office, but the form for this resident allowed for a maximum gap of 2 3/8 inches, while the observed gap exceeded this measurement. The mattress was also found to be easily compressed, further increasing the gap beyond regulatory limits. The assessment for bed system entrapment zones was only completed on one day and did not specify whether the resident was in bed at the time of measurement. Additionally, the assessment did not include the required documentation of the maximum acceptable gap for the resident, as mandated by state guidelines. Review of the resident's medical record showed only one restraint/enabler assessment, which was completed after the surveyor identified the bed safety concerns. This assessment noted the use of bilateral assist rails but did not address measurements or entrapment risks. No other relevant assessments, measurements, or physician orders were found in the record to evaluate the resident's risk of bed rail entrapment, indicating a lack of ongoing monitoring and documentation as required by state regulations.
Noncompliance with Fire Alarm System Testing and Maintenance Standards
Penalty
Summary
A deficiency was identified regarding the testing and maintenance of the fire alarm system. The fire alarm system was not tested and maintained in accordance with an approved program that complies with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm and Signaling Code). Additionally, records of system acceptance, maintenance, and testing were not readily available as required by the cited standards. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Implement Fall Prevention and Supervision
Penalty
Summary
The facility failed to follow policies and procedures for falls, implement meaningful care plan interventions, and conduct post-fall neurological assessments for two residents, R65 and R66, who were reviewed for accidents and supervision. R65, who was admitted with Alzheimer's and Parkinson's diseases, experienced multiple falls, many of which were unwitnessed. The facility's documentation revealed a lack of immediate action to prevent future falls and inadequate supervision, as evidenced by R65 being found unsupervised and without necessary safety equipment, such as a Dycem mat in his chair. Additionally, there was no documentation of neurological checks following suspected falls, despite the facility's policy requiring such assessments. R66, who was cognitively intact but had limited range of motion and a history of falls, also experienced numerous unwitnessed falls. The facility's records showed that R66's care plan did not adequately address his specific needs, such as orthostatic hypotension and metabolic encephalopathy, which were contributing factors to his falls. Despite repeated incidents, the care plan interventions were often repetitive and not tailored to address the root causes of the falls. Furthermore, R66 was observed alone in his room multiple times, contrary to the care plan's directive for constant supervision in common areas. Interviews with the Director of Nursing (DON) revealed that the facility's investigations into the falls were not thoroughly documented, and there was a lack of consistent implementation of care plan interventions. The DON acknowledged the deficiencies in documentation and supervision but did not provide additional information or documentation to address the concerns raised during the survey. The facility's failure to adhere to its policies and procedures for fall management and supervision resulted in repeated falls and injuries for both residents, highlighting significant deficiencies in the quality of care provided.
Deficiencies in Kitchen Maintenance and Equipment Labeling
Penalty
Summary
The facility failed to maintain its physical facilities and equipment in proper condition, as observed during a kitchen tour. Key issues included the absence of a handwashing reminder sign at the handwashing area, which is required by the FDA 2017 Food Code to notify food employees to wash their hands. Additionally, two water filters supplying water to the ice and water machines were found undated and unlabeled, with the Dietary Manager unaware of when they were last changed or their lifespan. This lack of information and documentation is contrary to the FDA 2017 Food Code requirements for scheduling inspection and service for water system devices. Further observations revealed two drain lines discharging water directly onto the floor beneath the ice machine, causing standing water and a white substance on the floor and wall. The kitchen's coving was removed from floor/wall junctures, making the area no longer smooth, non-absorbent, and easily cleanable, as required by the FDA 2017 Food Code. Additionally, the wall behind the steamer unit needed repair due to visible wall joists and missing board and coving, which contravenes the FDA 2017 Food Code's requirement for physical facilities to be maintained in good repair and designed to be smooth and easily cleanable.
Failure to Inform Medical DPOA of Psychoactive Medication Use
Penalty
Summary
The facility failed to properly inform the designated medical decision-makers for a resident, identified as R71, about the risks, benefits, and alternatives of psychoactive medications prescribed for dementia care. R71, who was cognitively intact according to a recent assessment, had been determined unable to make medical decisions by their attending physician. The resident had designated DPOA R and DPOA S as medical decision-makers, but the facility instead informed DPOA Q, who was only authorized for financial decisions, about the medications. This resulted in the responsible medical parties being uninformed about the resident's treatments. The facility's records did not include contact information for the designated medical DPOAs, and there was no documentation of any attempts to contact them regarding R71's medical care. Despite being informed by DPOA Q that DPOA S was unable to make decisions due to terminal cancer and that DPOA R was the primary medical decision-maker, the facility continued to rely on DPOA Q for medical decisions. The Director of Nursing confirmed that DPOA Q had been notified for medical decisions, acknowledging the lack of documentation involving DPOA R and DPOA S in care conferences or medical decision-making processes.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to conduct a timely care conference for a resident, identified as R43, which resulted in the potential for the resident and/or their responsible party not having an opportunity to participate in their person-centered plan of care. R43, a resident with a history of cerebral infarction, dementia, and depression, was admitted to the facility and had an initial care conference on 8/12/24. However, no subsequent care conferences were scheduled or attempted, despite the requirement for such conferences to occur at least every three months. This lapse occurred even after R43 was determined to be unable to make medical treatment decisions on 8/16/24. The Social Services Director confirmed that no care conferences had been held since the initial one, citing an upcoming court date for guardianship as a reason for the delay. The facility had petitioned the court for the appointment of a guardian, as the current patient advocate was not participating in care conferences. Despite this, the facility did not attempt to schedule any care conferences for R43, leaving a gap of over five and a half months without a care conference, and potentially extending to six months by the time the next conference would be scheduled.
Failure to Notify Medical DPOA of Resident's Treatment Preferences
Penalty
Summary
The facility failed to notify the responsible party of a resident's preferred treatment options, which is a violation of the resident's rights. The resident, who was admitted with diagnoses including Alzheimer's Disease, dementia with behaviors, depression, and anxiety, was determined by physicians to be unable to make medical decisions. Despite having a Durable Power of Attorney (DPOA) for medical decisions, the facility did not have contact information for the designated DPOA individuals, DPOA R and DPOA S, and instead contacted DPOA Q, who was only authorized for financial decisions. The facility's records did not document any attempts to notify the correct medical DPOA about the resident's treatment preferences, which included hospitalization for treatments beyond the nursing home's capabilities but excluding resuscitation. The Director of Nursing confirmed that DPOA Q was contacted for medical decisions, despite not being the designated medical DPOA, and acknowledged the lack of documentation regarding communication with the appropriate DPOA. This oversight was compounded by the fact that DPOA S was terminally ill and unable to make decisions, and DPOA R's contact information was missing from the records.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and personalized care plan for a resident, identified as R15, who was admitted with multiple health conditions including Multiple Sclerosis, a history of stroke, hemiplegia, and anxiety. Despite being cognitively intact, as indicated by a BIMS score of 15, the care plan for R15 lacked individualized and measurable interventions to help the resident achieve her goals of losing weight and becoming stronger. The care plan only included general interventions such as arranging care conferences and reviewing MDS Section Q with referrals as needed, without specific actions to promote the resident's physical well-being. Interviews with facility staff, including the Director of Nursing, Social Services Directors, and the Clinical Care Coordinator, revealed a lack of personalized efforts to assist R15 in achieving her goals. Although staff encouraged R15 to get out of bed and perform range of motion (ROM) exercises, documentation showed that these efforts were not comprehensive or consistently implemented. The resident often refused the ROM exercises, and there was no further documentation to demonstrate a concerted effort to maintain or improve her mobility. The deficiency was further highlighted when R15 herself stated that staff were not performing any daily ROM exercises with her.
Deficiency in Catheter and Wound Care for Resident
Penalty
Summary
The facility failed to provide appropriate assessments and care for a resident with a suprapubic catheter, leading to a deficiency in addressing skin conditions. The resident, who is cognitively intact, expressed concerns about her catheter becoming plugged and leaking, which was not promptly addressed. During an observation, an LPN changed the gauze at the catheter insertion site without measuring or assessing the wound, which was approximately the size of a marble. The facility's records, including the Minimum Data Set and Treatment Administration Record, did not document the wound at the catheter insertion site or indicate that catheter care was consistently performed as ordered. Further review revealed that the resident's care plan included interventions for skin impairment and catheter care, but there were no specific orders for wound care at the catheter insertion site. An LPN reported noticing increased drainage at the site and communicated with a Nurse Practitioner, who ordered the use of an antimicrobial foam. However, the electronic medical record did not reflect any new skin assessments or orders for wound care, indicating a lack of documentation and follow-up on the resident's condition.
Failure to Provide Restorative Care and ROM Interventions
Penalty
Summary
The facility failed to provide appropriate restorative care and range of motion (ROM) interventions for a resident with quadriplegia, weakness, and rheumatoid arthritis. The resident, identified as R10, was observed on multiple occasions without the prescribed finger flexion gloves, which are part of her restorative nursing program to prevent decline in hand function. Despite the occupational therapist's instructions for the gloves to be worn for 30 minutes in the morning and evening, the resident reported that staff did not apply them consistently. The gloves were found across the room, indicating they were not in use as required. Further investigation revealed a lack of documentation in the resident's electronic medical record (EMR) regarding the application of the gloves and any passive range of motion (PROM) services. The licensed practical nurse (LPN) confirmed the absence of documentation and noted that the resident sometimes refused the gloves, although there was no record of refusals or follow-up actions in the progress notes. The care plan included the use of finger flexion gloves but did not address active or passive ROM, and there were numerous instances of unrecorded or refused tasks related to the restorative program.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care, specifically oxygen therapy, as required. The resident, who has chronic obstructive pulmonary disease (COPD) and is dependent on supplemental oxygen, reported that staff sometimes did not apply her BiPAP machine at night. During an observation, the BiPAP machine was seen on the nightstand next to her bed, but there were no active orders for its use in the electronic medical record (EMR). Additionally, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 lacked documentation of the BiPAP machine being applied. The resident's care plan indicated the need for respiratory equipment, including the use of BiPAP at bedtime, initiated in May 2023. An interdisciplinary progress note from November 2024 also highlighted the resident's occasional shortness of breath while lying flat, requiring BiPAP use. The Director of Nursing confirmed the absence of active orders and documentation for the BiPAP therapy, noting that orders were not restarted after the resident's return from the hospital.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper communication and monitoring for a resident requiring dialysis care. The resident, who was admitted with diagnoses including diabetes and kidney disease, was dependent on hemodialysis three times a week. Despite having a care plan in place that required communication with the dialysis center and post-dialysis monitoring, the facility did not adhere to these protocols. Licensed Practical Nurse (LPN) C, who routinely cared for the resident post-dialysis, reported that there was no communication paperwork exchanged between the facility and the dialysis clinic. Furthermore, the dialysis communication forms uploaded into the electronic medical record (EMR) were not reviewed by clinical staff, as confirmed by the Director of Nursing (DON) and Medical Records Manager (MRM) B. Additionally, the facility did not conduct the necessary post-dialysis assessments as outlined in the resident's care plan. LPN C admitted to not obtaining new vital signs upon the resident's return from dialysis and instead filled in the morning vital signs on the Post Dialysis Assessment Care Plan. The DON confirmed that weight, vital signs, and assessments should be conducted after dialysis, and the dialysis communication forms should be reviewed each time the resident returned from treatment. The facility's policy on dialysis communication, effective since December 2021, emphasized the importance of ongoing assessment and collaboration with the dialysis facility, which was not followed in this case.
Medication Labeling Deficiency in Facility
Penalty
Summary
The facility failed to ensure proper labeling of medications in one of the medication carts and one of the medication rooms inspected. During an observation, a Breo-Elipta discus belonging to a resident was found in a box labeled with the resident's name, but the discus itself was not labeled with any identifying information. The LPN stated that nurses usually do not label the discus with the resident's name because it comes in a labeled box, but they do label it with the resident's room number in case it gets separated. However, in this instance, the discus was not labeled with either the resident's name or room number. Additionally, an open vial of Tuberculosis Purified Protein Derivative (TB PPD) was found in a medication room without an open date labeled on the vial itself, although the box had an open date. The RN confirmed that without the box, the open date would be unknown. There was inconsistency among staff regarding the labeling requirements for TB vials, with one LPN stating they should be labeled with an open date and another stating they are good for 30 days in the refrigerator. The Director of Nursing confirmed that individual vials, inhalers, and discus should be labeled with the resident's name when boxes are opened, and TB vials should be labeled with an open date, but was unsure of the exact duration for which a TB vial remains usable after opening.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation. For one resident, the Social Services Director (SSD) failed to document a care conference in the electronic medical record (EMR) on the correct date. The SSD initially claimed the conference occurred on a date when the resident was hospitalized, and later could not confirm the actual date from handwritten notes. This discrepancy highlights a lack of timely and accurate documentation, as the facility's policy requires entries to be made as soon as possible after an event. Another resident's care conference was not documented in the EMR, despite being scheduled and reportedly conducted. The SSD admitted to not entering the notes into the system. Similarly, for a third resident, a care conference was conducted but not documented in the EMR, with the SSD acknowledging the oversight. These failures in documentation contravene the facility's policy and the American Nursing Association's principles, which emphasize the importance of timely, accurate, and complete documentation to ensure informed decisions and high-quality care.
Failure to Implement Effective Infection Control for Recurrent UTIs
Penalty
Summary
The facility failed to implement appropriate infection control interventions and conduct a root cause analysis for a resident with recurrent urinary tract infections (UTIs). The resident, who has Alzheimer's disease, dementia with behavioral disturbances, and a history of UTIs, was admitted to the facility and experienced multiple UTIs over several months. Despite the frequent occurrence of UTIs, the facility did not identify any trends or implement new interventions to prevent these infections. The Infection Preventionist/Registered Nurse (RN) reported that the facility commonly sees UTIs and skin infections but did not provide specifics on infection control audits or interventions for the resident's UTIs. The resident's care plan included bowel and bladder planning and assistance with toileting, but no new interventions were added despite the recurrent E. coli infections. The facility's policy on antimicrobial stewardship emphasizes the importance of obtaining cultures before administering antibiotics, but the resident was repeatedly started on antibiotics before culture results were available, leading to changes in medication once results were received. The resident's urinalysis history showed positive results for UTIs on multiple occasions, with E. coli being the main bacterial growth. The facility's failure to implement effective infection control measures and conduct a thorough root cause analysis contributed to the resident's ongoing UTIs. The Infection Preventionist acknowledged the resident's resistance to care and fluctuating behaviors but did not provide comments on the origins of E. coli or potential preventative measures.
Failure to Provide Increased Supervision Leads to Resident's Fall and Death
Penalty
Summary
The facility failed to provide increased supervision for a resident who was at risk for falls, resulting in a fall with neck fractures and subsequent death. The resident, a male with a history of a broken femur, multiple pelvic fractures, highly impaired vision, hearing difficulties, and chronic kidney disease, was admitted to the facility after a hospital stay. The hospital discharge summary noted issues with altered mental status, possibly related to dementia and hospital delirium, and the resident was prescribed medications that could cause sedation and confusion. Upon admission, the resident was assessed as alert and oriented but had sundowning syndrome. Despite being at risk for falls due to his medical condition and debility, the resident did not receive his prescribed pain medication, Norco, for over two days after admission. The resident exhibited signs of pain and confusion, which were not adequately addressed by the facility staff. A nurse practitioner noted the resident's symptoms and ordered an increased dose of Norco, but was unaware that the medication had not been administered as prescribed. The facility's interdisciplinary team noted a change in the resident's cognitive status, but there was no evidence of increased supervision or safety measures being implemented. The resident eventually fell, sustaining multiple spinal fractures, and was found in a state of septic shock, possibly due to pneumonia and a urinary tract infection. The resident was admitted to the hospital's trauma service and later died from injuries related to the fall. The death certificate indicated that the fall in the facility directly caused the resident's death.
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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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