The Orchards At Three Rivers
Inspection history, citations, penalties and survey trends for this long-term care facility in Three Rivers, Michigan.
- Location
- 55378 Wilbur Rd, Three Rivers, Michigan 49093
- CMS Provider Number
- 235354
- Inspections on file
- 22
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at The Orchards At Three Rivers during CMS and state inspections, most recent first.
Surveyors identified widespread environmental uncleanliness and poor housekeeping practices, including resident rooms with trash, dust, food debris, stained floor mats, and damaged surfaces, as well as shared bathrooms with unflushed urine, brown smears and splatters resembling fecal matter on toilets, walls, and floors, sticky floors, deteriorated grip strips, and buildup around toilet bases. In the memory care unit, hallways, dining areas, and wall-mounted fans had heavy dust and debris accumulations that persisted over multiple days, and spa/shower rooms contained dust, dead bugs, crusted debris on shower chairs, ants, and other visible soil. Some residents with dementia and cognitive communication deficits were observed in these dirty environments, while cognitively intact residents reported dissatisfaction with room cleanliness and infrequent bedding changes. The Ombudsman reported ongoing cleanliness complaints from residents and families, and housekeeping staff stated that only two housekeepers cleaned the entire building daily and that CNAs were expected to clean visible bowel and urine contamination before housekeeping would disinfect, while a CNA reported leaving a resident alone in the bathroom and not returning to assist with cleanup.
A resident with severe cognitive impairment and multiple comorbidities developed a UTI confirmed by abnormal urine labs and culture, leading the physician to order daily IM ceftriaxone. Nursing staff documented administration of the IM antibiotics over several days without adverse reactions, but there was no documentation that the resident’s POA/responsible party was notified of the abnormal lab results, UTI diagnosis, or new antibiotic orders. The POA later learned of the treatment only when the resident mentioned receiving injections, and facility staff acknowledged that resident representatives should be notified of new infections, changes in condition, new orders, and abnormal labs for cognitively impaired residents.
Multiple deficiencies were identified in food safety and sanitation, including improper food labeling and storage, inadequate hand hygiene, inaccessible handwashing sinks, and poor monitoring of refrigerator temperatures. Dietary staff were observed not following required practices such as wearing hair restraints, washing hands between tasks, and ensuring food items were properly cooled, labeled, and stored. Structural and cleanliness issues in kitchen and storage areas further contributed to unsafe food handling conditions.
The facility did not effectively manage its staffing and meal service, leading to insufficient staff coverage, long call light wait times, missed showers, and inadequate assistance for residents. Residents and staff reported poor food quality, small portions, missing dietary supplements, and inconsistencies between posted menus and actual meals. Despite repeated concerns raised to management, no effective corrective actions were implemented.
Multiple residents experienced missed or uncomfortable showers due to persistent hot water shortages, and several reported or were observed living in rooms with peeling paint, debris, and unsanitary conditions. Staff interviews confirmed ongoing hot water issues and inadequate maintenance, while observations revealed additional facility-wide cleanliness and maintenance deficiencies.
Several residents with significant physical and cognitive needs did not receive showers or baths as scheduled according to their care plans, with missed bathing days, lack of hot water, and short-staffing contributing to the deficiency. Residents and families reported dissatisfaction with hygiene care, and facility documentation was inconsistent regarding missed or refused showers.
Multiple residents reported missed showers, long call light wait times, and unmet personal care needs due to insufficient staffing. Staff interviews confirmed frequent unfilled positions, minimal management intervention, and routine omission of essential care tasks when short-staffed. Facility documentation and policies indicated higher staffing expectations than what was provided, resulting in delayed or omitted care.
The facility did not consistently follow the scheduled menu, failed to clearly post the current menu cycle for residents, and did not update the menu when changes occurred. A resident with multiple health conditions reported frequent inconsistencies between the posted menu and meals served, and dietary staff confirmed confusion about the menu cycle and substitutions based on ingredient availability.
Multiple residents and family members reported that meals were often bland, unrecognizable, served in small portions, and delivered at temperatures below recommended levels. Staff interviews and test tray observations confirmed that food was frequently cold, lacked flavor, and that dietary shortages led to substitutions and missing supplements. These deficiencies resulted in widespread dissatisfaction and inconsistent provision of appropriate diets.
Two residents did not receive their ordered medications on time due to administrative delays and lack of timely authorization or prescription signatures. One resident with a severe infection missed all doses of a prescribed IV antibiotic, leading to worsening symptoms and hospital transfer, while another resident with a seizure disorder missed multiple doses of an anti-seizure medication because of delays in obtaining a signed prescription.
A resident with severe cognitive impairment was prescribed and administered multiple psychotropic medications without documented informed consent from the resident's representative. Family members were not notified of medication changes and only learned about the medications after reviewing a list provided by the facility. Facility staff confirmed the absence of signed consent forms for these medications, and verbal consent was only documented after the medications had already been administered.
A resident with severe cognitive impairment and dementia was prescribed Haldol and Olanzapine without a proper psychiatric diagnosis or adequate documentation. Staff administered these psychotropic medications without consistently attempting non-pharmacological interventions or monitoring for side effects, leading to increased sedation, weight loss, falls, and decreased ability to communicate. The resident's guardian was not properly informed of medication changes, and care plans lacked necessary details, resulting in significant harm including dehydration and hospitalization.
The facility did not complete required annual performance reviews for three CNAs who had been employed for over a year, as confirmed by personnel file reviews and staff interviews. This omission resulted in the potential for unidentified staff performance concerns and unmet training needs, contrary to facility policy.
The facility did not ensure its QAPI program identified and corrected quality deficiencies, particularly in dementia care. A resident with dementia did not receive individualized care despite interventions provided by her DPOA, and staff lacked knowledge on managing her stress responses. The QAPI committee failed to review data or develop action plans for identified concerns, and issues such as psychotropic medication use and staff training were not adequately monitored.
The facility did not ensure that the medical director or a designee attended QAPI committee meetings at least quarterly, as required by policy. Sign-in sheets confirmed no attendance by the medical director or designee over several months, with management turnover and a change in medical directors contributing to the deficiency.
The facility did not maintain an effective staff training program, resulting in missing documentation and lack of required training in areas such as QAPI, infection control, compliance and ethics, communication, and resident rights for multiple employees. The DON and NHA confirmed that training was not tracked and that no performance improvement plan was in place to address these deficiencies.
The facility did not implement or document an effective in-service training program for CNAs, resulting in a lack of evidence for the required 12 hours of annual training. The DON reported the absence of a staff educator and no current training plan, while the NHA confirmed non-compliance with training requirements. Personnel files reviewed did not show completion of mandatory training.
A resident with severe cognitive impairment and vascular dementia experienced ongoing wandering, frustration, and stress due to the facility's failure to implement individualized dementia care interventions, incorporate input from the resident's DPOA, and provide appropriate activities or staff training. The care plan was incomplete and did not address known triggers or effective calming techniques, and staff reported insufficient training and resources to meet the needs of dementia residents.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately documented as participating in group activities and outings, including after discharge, despite staff and DPOA statements confirming non-participation. The care plan also listed an incorrect nickname, and the activity attendance records contained errors acknowledged by the Activity Director.
A resident with severe cognitive and visual impairments did not receive individualized, meaningful activities to support leisure needs. Documentation inaccurately reflected participation in activities that the resident was unable to perform, and staff did not consult the resident's DPOA for past interests. Interviews confirmed the resident required one-on-one support and was not engaged in appropriate activities, highlighting a lack of resident-centered programming in the memory care unit.
A resident with severe cognitive impairment and high ADL assistance needs was repeatedly observed with a call light placed out of sight and reach, either under the sheet or clipped at the head of the bed. The unit manager confirmed staff intentionally positioned the call light this way, but acknowledged it should have been accessible.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
A resident requiring dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to meet established standards for such care.
A narcotic medication intended for a resident was left unattended in a medication cup on top of a medication cart in a secure unit's common area, with multiple residents and staff present but not monitoring the cart. The medication, identified as Lorazepam, remained out of staff supervision for 37 minutes, contrary to facility policy requiring direct observation or secure storage of controlled substances.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Staff failed to use a gait belt when assisting a resident with ambulation despite the resident's history of weakness and hip fracture, and another resident with severe cognitive impairment was transported in a wheelchair without footrests in place. Staff interviews confirmed that both actions were contrary to facility policy and training.
The facility did not ensure that a qualified Infection Preventionist was dedicated at least part-time to infection control duties, as the staff member assigned to this role was also serving as ADON and Unit Manager, with significant additional responsibilities. This resulted in limited time for infection control activities, insufficient staff education on PPE use for Enhanced Barrier Precautions, and audits that did not assess staff compliance, leading to a failure in properly managing the infection prevention and control program.
The facility did not ensure the dietary manager had the necessary skills and presence to manage food and nutrition services, resulting in missed menu items, use of emergency food supplies, and lack of essential dietary products. Staff were unclear about food ordering processes, and both the dietary manager and interim manager were only PRN, leading to inconsistent oversight and potential unmet nutrition and hydration needs for residents.
Dietary staff were unable to follow planned menus due to insufficient food supplies and made unapproved substitutions without notifying the RD or documenting changes. The RD had not been present or informed of substitutions, and required oversight and documentation were lacking, resulting in unmet nutritional needs for residents.
Two residents with indwelling medical devices requiring enhanced barrier precautions were not provided appropriate PPE use by staff during high-contact care activities. Despite facility policy, posted signage, and staff education, staff were observed assisting these residents without donning gowns or gloves, and interviews revealed confusion and noncompliance regarding EBP requirements.
A resident with severe cognitive impairment and a Foley catheter did not have a care plan addressing enhanced barrier precautions, despite staff and facility expectations that such precautions should be implemented and care planned. The care plan only addressed fall risk and urinary retention, omitting necessary interventions for infection prevention related to the catheter.
A resident with severe cognitive impairment and a history of traumatic brain injury had changes in diet and hydration orders, but the care plan was not updated to reflect these changes. Staff interviews and observations revealed outdated care plan documentation, confusion over responsibility for updates, and discrepancies between current orders, visual cues, and the care plan, resulting in an inaccurate description of the resident's care needs.
Two residents with physical disabilities did not receive scheduled showers for extended periods, with documentation showing gaps of up to 12 days between showers and no recorded refusals. Staff interviews revealed that showers were often missed during busy or understaffed shifts, and the only documentation method was through shower sheets signed by nurses. The DON confirmed that staffing issues were not an acceptable reason to skip showers, but the facility failed to ensure consistent ADL care.
Three residents with cognitive impairments experienced incidents including altercations and an elopement due to the facility's failure to provide adequate supervision, update care plans, and maintain environmental controls such as locked doors. Staff were unaware of or did not implement necessary interventions, and documentation of incidents and behavioral issues was incomplete.
The facility failed to maintain cleanliness and repair, with issues such as direct wastewater connections in the kitchen, missing light shields, and raw wood storage racks. Debris accumulation was found in resident and dining areas, and housekeeping staff shortages affected cleanliness. The beauty shop lacked a vacuum breaker, risking potable water safety.
The facility failed to provide annual abuse prevention education for all employees, affecting 73 residents. The ADON was unaware of her training responsibilities and lacked access to the electronic training program. The DON reported that the facility could not continue the previous owners' training program, leading to 91 out of 128 staff members missing required training.
The facility failed to implement an active infection prevention and control program for legionella and other pathogens. Observations revealed that water samples had not been tested in over a year, and the Water Management Plan was not being followed. The Maintenance Director was unsure about control measures and the status of water lines, indicating a lack of systematic monitoring and documentation.
The facility failed to control hot water temperatures, leading to a risk of scalding and burns for residents. During a tour, hot water temperatures in various areas, including the Riverside Spa and Meadowlane Spa, were found to exceed 120°F, with some reaching up to 135°F. The Maintenance Director noted usual temperatures between 116°F and 118°F, but the boiler was set at 140°F, affecting the entire building. Staff were observed adjusting water temperatures manually for residents. The surveyor informed the ADON of the increased risk of harm.
A facility failed to maintain nebulizer equipment for a resident with COPD, leading to potential risks of infection. Observations showed the nebulizer machine and tubing were improperly stored and outdated. Staff interviews confirmed that equipment should be changed weekly and stored properly, but the outdated kit was used during a respiratory distress episode, resulting in the resident's transfer to acute care. Facility policy required equipment changes every 72 hours and proper storage.
The facility failed to obtain COVID-19 vaccination consents or declinations for two residents, leading to a deficiency in ensuring informed consent. A severely cognitively impaired resident received a Pfizer Booster without her POAs being contacted, while a cognitively intact resident refused the Moderna Booster without being provided a consent form. The Assistant Director of Nursing admitted that correct consent forms were unavailable until late October, contributing to the documentation failure.
The facility failed to properly document and notify regarding resident transfers, using incorrect forms for a resident-initiated discharge and not notifying the local ombudsman. A resident with significant health issues was sent to the ER with an incomplete transfer form, lacking destination and reason details.
The facility failed to update care plans for two residents, leading to deficiencies in fall prevention and contracture management. A resident with paraplegia did not have a necessary bolster intervention added to their care plan after a fall, while another resident's care plan incorrectly indicated the use of a discontinued soft hand splint. Observations and staff interviews confirmed these discrepancies.
The facility failed to provide required behavioral health and dementia training to 68 out of 128 staff members. The ADON was unaware of her training responsibilities, and the facility lacked access to an electronic training program due to ownership changes. The facility relied on in-person education, but records showed non-compliance with training requirements, leading to a deficiency report.
A resident with severe cognitive impairment and high elopement risk was found unsupervised in the parking lot of an LTC facility. Despite lacking authorization to leave, the incident was not reported as an elopement, and no investigation was conducted. Staff interviews revealed the resident was disoriented and had a history of wandering and falls, making it unsafe for him to be outside alone.
A facility failed to create a person-centered care plan for a resident at high risk for elopement, leading to the resident exiting the building unsupervised. The resident, who was severely cognitively impaired and used a wheelchair, was found confused in the parking lot. Despite being assessed as high risk for elopement, no specific interventions were included in the care plan to address this risk.
A facility failed to prevent an elopement of a cognitively impaired resident and did not maintain a mechanical lift, leading to a resident's fall. The resident at high risk for elopement was found unsupervised outside, and the facility did not follow its elopement protocol. Another resident suffered a head injury due to a poorly maintained lift. The facility lacked a maintenance schedule and inventory system for equipment, contributing to these deficiencies.
The facility failed to assess an acute change of condition in one resident and provide appropriate wound care for another. Despite multiple reports from CNAs, the LPN did not perform an assessment or notify the physician in a timely manner, leading to severe dehydration and hypernatremia. Another resident's wound care was inconsistently documented and administered, increasing the risk of infection.
Widespread Environmental Uncleanliness and Poor Housekeeping Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, orderly, and homelike environment in resident rooms, shared bathrooms, hallways, and common areas, as well as inadequate housekeeping response to visible soil and bodily substances. Multiple cognitively intact residents reported dissatisfaction with the cleanliness of their rooms, including one resident whose window had a long streak of old tape and residue that had been present since admission, and another who had tied bags of soiled linens and trash left on the floor near her bed along with trash and debris under and around the beds. Other residents’ rooms were observed with visibly soiled floors, paper and food debris, dust and trash accumulations under beds and along walls, and soiled floor mats with dried stains that remained unchanged over multiple days. In one room, a large dried spill or stain was present on the floor near dialysis equipment, and a wall gouge was noted near the bed. Additional observations showed that several residents with dementia, cognitive communication deficits, and muscle weakness were living in rooms with dirty floor mats, crumbs and debris in mat seams, and stained walls adjacent to their beds. Shared bathrooms between resident rooms were repeatedly observed with unflushed urine in toilets, brown smears and splatters resembling fecal matter on toilet seats, bowls, walls, and floors, sticky/tacky floors, dust and debris around perimeters and baseboards, deteriorated grip strips that were torn and peeling, and darkened buildup or damaged caulk around toilet bases. These unsanitary conditions persisted across multiple observations on different days, including one bathroom that continued to have dirt, debris, stale urine odor, sticky floors, and dried brown splatter resembling fecal matter on and around the toilet despite prior similar findings. The memory care unit and spa/shower rooms were also found in unclean condition. In the locked memory care unit, surveyors observed heavy accumulations of dust and debris at double doors, in the dining room corners and along walls, and on wall-mounted fan blade guards, with these accumulations remaining unchanged on subsequent days. Hallways outside resident rooms contained trash, broken plastic pieces, and large dust balls. In spa and shower rooms, there were dust and dead bugs in the bottom of a spa tub, brown crusted debris on a shower chair, dozens of small ants on the floor emerging from floor junctures, and white wet debris resembling toilet paper on another shower chair. During a confidential resident council meeting, most residents present reported that rooms and shared spaces were not consistently kept clean and some reported bedding was not changed frequently enough. The Ombudsman reported ongoing complaints from residents and families about facility cleanliness over several months. Housekeeping staff stated that only two housekeepers were responsible for cleaning all resident rooms and the locked unit daily, and described a process in which CNAs were expected to clean visible bowel movements and urine before housekeeping would disinfect, while a CNA acknowledged leaving a resident unsupervised in the bathroom and not returning to assist with cleanup after toileting.
Failure to Notify Responsible Party of UTI Diagnosis and Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a change in condition, specifically a newly identified urinary tract infection (UTI) and initiation of antibiotic treatment. The resident was an adult female with dementia, depression, muscle weakness, a cognitive communication deficit, and a documented need for assistance with personal care. Her MDS assessment showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The admission record identified a family member as the resident’s POA for care, first emergency contact, and responsible party. During an interview, this family member reported that the facility had not been consistently notifying her of changes in the resident’s condition and that she only learned of the UTI treatment when the resident mentioned she was receiving “shots” during a visit. Record review showed that on a specified date, the physician evaluated the resident’s urine after a nursing request and documented pyuria, bacteriuria, and a urine culture with more than 100,000 organisms of Proteus mirabilis, sensitive to Rocephin. The physician’s plan included Rocephin 1 g IM daily, and an order was entered for ceftriaxone IM once daily for five days for UTI. Nursing notes documented administration of IM antibiotic injections on multiple days with no adverse reactions. However, there was no documentation in the medical record that the responsible party was notified of the abnormal lab findings, confirmed UTI, or new antibiotic orders. The administrator confirmed the facility could not locate documentation of such notification, and both an LPN and an RN stated in interviews that for cognitively impaired residents or those who are not their own responsible party, the resident representative should be notified of newly identified infections, changes in condition, new physician orders, and abnormal lab results.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain professional standards of food service safety, as evidenced by multiple observations of improper food handling, storage, and sanitation practices. Dietary staff were observed not wearing required hair restraints during food service, and there was a lack of knowledge and documentation regarding the proper cooling and temperature monitoring of leftover foods. Open food items in various storage areas were frequently found without proper labeling, dating, or secure sealing, and some items were stored past their use-by or discard dates. Additionally, food was found stored open and exposed in the freezer, and some items requiring refrigeration were left unrefrigerated after opening. Sanitation and cleanliness issues were prevalent throughout the kitchen and nourishment rooms. Water leaks were observed in dry storage and pantry areas, with makeshift coverings such as blankets used to contain puddles. The walk-in cooler had structural deficiencies, including gaps at the floor juncture and a loose door latch, allowing for potential pest entry and cold air escape. Accumulations of dirt, debris, and food residue were noted on storage racks and floors, and clean pots and pans were found with encrusted grease. Air conditioning units above food preparation areas were heavily soiled, and the dish machine's pressure gauge was not being monitored as required, with staff unaware of proper temperature verification methods. Hand hygiene practices were inadequate, with staff observed failing to wash hands after changing tasks, touching their face masks, or using their phones, and one staff member was seen wearing artificial nails without gloves while handling food. Handwashing sinks were either out of order or blocked by carts, limiting accessibility. Refrigerator temperature logs showed repeated instances of temperatures above the safe threshold, with unclear responsibility among staff for monitoring and addressing these issues. There was also a lack of documentation when food was discarded due to unsafe temperatures. These deficiencies collectively created an environment with a potential for foodborne illness among residents consuming food from the kitchen.
Failure to Ensure Adequate Staffing and Meal Service
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, specifically regarding staffing and meal service. Multiple interviews and record reviews revealed ongoing issues with insufficient staffing, resulting in long call light wait times, missed showers, and inadequate assistance with transfers and care. Residents reported that aides were overworked, and staff often responded to call lights without returning to provide needed care. Staff interviews confirmed that holes in the schedule frequently went unfilled, with night shifts sometimes staffed by only one or two nurses for the entire building, including high-acuity units. Staff were reportedly discouraged from contacting the DON about staffing concerns, and showers were often not completed when staffing was low. Additionally, the facility failed to provide adequate meal service, with residents and staff reporting small portion sizes, unrecognizable or inedible food, and inconsistencies between the posted menu and actual meals served. There were instances where basic food items, such as bread and syrup, were unavailable, and dietary supplements were not consistently provided. Both residents and the Ombudsman reported that these concerns had been communicated to management, but no improvements were observed. The administration acknowledged awareness of these issues but did not implement effective corrective interventions, resulting in ongoing deficiencies impacting all residents.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents, as evidenced by ongoing issues with hot water availability, unaddressed maintenance concerns, and unsanitary conditions. One male resident with Parkinson's disease, legal blindness, and dementia reported missing scheduled showers due to a lack of hot water, an issue persisting for months. Another female resident with cerebral palsy and muscle weakness also reported frequent hot water shortages during showers and was observed in a room with significant peeling paint and debris on the floor. A third male resident with diabetes and debility described his room as dirty upon admission, with chipped paint and a dirty pillow on the floor. Observations confirmed the presence of peeling paint, rusted door frames, chipped tiles, foul odors, and trash in common areas, as well as a damaged American flag and discarded gloves outside the facility. Staff interviews corroborated the residents' complaints, with an LPN acknowledging recent hot water issues in the shower room and the Maintenance Director stating that staff were instructed to let the water run to warm up. Despite these instructions, residents continued to experience discomfort and dissatisfaction with their living conditions, including missed showers and exposure to unclean and deteriorating environments.
Failure to Provide Showers/Baths per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide showers and baths according to resident preferences and care plans for four out of seven residents reviewed. Multiple residents with significant physical and cognitive impairments, including those with stroke, Parkinson's disease, cerebral palsy, and Huntington's disease, did not receive scheduled showers as documented in their care plans and physician orders. Documentation revealed missed showers on several scheduled days, with no record of completion or refusal, and residents reported not receiving the expected number of showers per week. Residents and their family members reported dissatisfaction with the frequency and quality of bathing, citing issues such as lack of hot water, short-staffing, and missed scheduled shower days. One resident reported that the facility had ongoing problems with hot water, resulting in missed showers or incomplete bathing experiences. Family members corroborated these concerns, noting that they sometimes had to provide showers themselves due to inadequate hygiene care at the facility. The facility's documentation practices were inconsistent, with some missed showers lacking any explanation or record. Staff interviews confirmed that shower schedules were in place and that documentation was expected, but there were gaps in both the provision of care and the recording of refusals or missed showers. These failures led to resident dissatisfaction and the potential for discomfort and impaired self-worth, as residents were not consistently assisted with activities of daily living as required by their care plans.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of long call light wait times, missed showers, and unmet personal care needs. Several residents, all cognitively intact, reported not receiving scheduled showers, experiencing delays in assistance, and being left in situations where their hygiene and dignity were compromised. Documentation confirmed missed showers for multiple residents, and interviews revealed that these issues were linked to both short-staffing and, in some cases, lack of hot water. Staff interviews consistently described inadequate staffing levels across various shifts and units, with frequent unfilled positions and minimal attempts by management to address these gaps. Nurses and CNAs reported that when staffing was low, essential care tasks such as showers were the first to be omitted, and residents often waited extended periods for assistance. Staff also indicated that management rarely assisted on the floor, and that holes in the schedule were common and not proactively filled, sometimes leaving only one CNA on a unit for several hours. The facility's own assessment and staffing policies outlined higher staffing expectations than what was routinely provided, particularly on the River and View Units. Despite these documented standards, actual staffing often fell below the stated requirements, with staff and residents both reporting that care was delayed or omitted as a result. The deficiency was further corroborated by the facility's policies, which require prompt response to call lights and sufficient staffing to meet resident needs, both of which were not consistently met according to the findings.
Failure to Follow and Clearly Post Current Menu Cycle
Penalty
Summary
The facility failed to follow the posted menu and serve food items as scheduled, did not post the current menu in a manner accessible for residents to review, and did not update the menu with changes when they occurred. Observations revealed that the menu posted in the main dining room was not clearly marked to indicate the current week of the menu cycle, requiring residents to flip through multiple pages to determine what meals were scheduled. There were no dates on the menu to clarify which week was current, and the menu visible was consistently for Week 4, regardless of the actual week. Interviews with dietary staff confirmed that meals served did not always match the scheduled menu due to issues such as missing ingredients and confusion among newer staff about which week of the menu cycle was being followed. A resident with cerebral palsy, major depression, muscle weakness, and a need for assistance with personal care reported that the food served was often inconsistent with the posted menu and that she was frequently unaware of what would be served until the meal tray arrived. Dietary staff acknowledged serving meals from different weeks and substituting menu items based on availability, rather than following the planned menu. These actions resulted in inconsistencies in meal service and a lack of clear communication to residents regarding their meal options.
Failure to Provide Palatable, Adequate, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide adequate portions of palatable food, served at an appetizing temperature, to multiple residents. Residents and their family members reported dissatisfaction with the quality, temperature, and portion sizes of the meals. Specific complaints included food being bland, flavorless, unrecognizable, and often served lukewarm or cold. Some residents, including those with visual impairments, were unable to identify their food, and staff were reportedly unable to provide information about the meals being served. There were also reports of food items being substituted due to shortages, such as sandwiches being made with hamburger buns instead of bread, and waffles being served without syrup due to lack of supplies. Observations and interviews revealed that residents frequently received small portion sizes, with some meals described as insufficient, such as a breakfast consisting of half a glass of orange juice, a hard-boiled egg, and a piece of toast. Residents with specific dietary needs, such as those requiring supplements or extra portions due to medical conditions, did not consistently receive appropriate food or supplements. There were also instances where residents received food inconsistent with their ordered diets, and staff had to improvise to make the food suitable for consumption, such as moistening dry ground meat with mayonnaise packets when gravy was unavailable. Test tray observations confirmed that food was served at temperatures below recommended levels, with hot foods such as chicken tenders, green beans, and stuffing measured at 104°F, 113°F, and 128°F, respectively, upon delivery to the unit. Dietary staff acknowledged shortages of key items like Magic Cups and yogurt, and nursing staff reported ongoing issues with cold food, small portions, and missing supplements. These findings were corroborated by multiple interviews with residents, family members, dietary staff, and nursing staff, all indicating persistent problems with food quality, temperature, and adequacy.
Failure to Administer Ordered Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were administered timely according to physician orders for two residents, resulting in delays in care. One resident, who had multiple serious diagnoses including MRSA infection, sepsis, and peripheral vascular disease, was admitted with orders for intravenous antibiotics. Despite the physician's order for Ceftaroline Fosamil to be administered every eight hours, the resident did not receive any doses during his stay because the medication was not available. The pharmacy required payment authorization due to the high cost, and the facility did not provide this authorization until several days after the order was placed. During this period, the resident's condition worsened, with increased pain and significant discoloration and necrosis of his toes, ultimately leading to a hospital transfer and subsequent above-the-knee amputation. Another resident, admitted with a seizure disorder, diabetes, and hypertension, also experienced a delay in receiving a critical medication. The resident was ordered to receive Lacosamide for seizure control twice daily, but missed a total of ten scheduled doses over several days. The delay was due to the lack of a signed prescription, which was not obtained promptly from the physician. Nursing staff documented that the medication was on order and that the physician was aware, but the prescription was not signed and accepted by the pharmacy until several days after admission. During this time, the resident did not receive the ordered seizure medication. In both cases, the facility did not follow its own policy requiring medications to be administered in accordance with physician orders. The delays were attributed to administrative and communication failures between the facility, pharmacy, and physician, resulting in missed doses of essential medications for both residents. The documentation shows that staff were aware of the missed doses and the reasons for the delays, but did not ensure timely resolution to provide the necessary care as ordered.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration and changes of psychotropic medications for one resident with severe cognitive impairment. The resident, who had diagnoses including psychotic disorder with delusions, depression, and unspecified dementia with agitation, was prescribed multiple psychotropic medications such as Duloxetine, Mirtazapine, Olanzapine, and Quetiapine. Despite the resident's cognitive status, there was no evidence that informed consent was obtained from the resident's representative prior to the initiation or adjustment of these medications. Family members reported they were not notified about changes to the resident's medications and only became aware of the use of certain psychotropic drugs after reviewing a medication list provided by the facility. The family expressed concern and confusion regarding the reasons for the prescriptions, indicating a lack of communication and education from the facility regarding the resident's medication regimen. The resident's spouse/guardian was not fully informed about all medications until a care conference was held, well after the medications had been prescribed and administered. Interviews with facility staff, including the social worker and the nursing home administrator, confirmed that there were no signed consent forms for the psychotropic medications in the resident's medical record, except for verbal consent documented during a care conference. The social worker acknowledged that, given the resident's severe cognitive impairment, consent should have been obtained from the spouse/guardian rather than the resident. The director of nursing also confirmed that consent is required for the administration of psychotropic medications, but such documentation was not present.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
A resident with severe cognitive impairment and a history of cerebral infarction, dementia, and behavioral disturbances was prescribed psychotropic medications, specifically Haldol (haloperidol) and Olanzapine (Zyprexa), without an adequate psychiatric diagnosis to justify their use. The medications were initiated and increased over time, despite the absence of documented psychiatric conditions such as schizophrenia or bipolar disorder. The care plan did not include a mental health diagnosis or PASARR documentation to support the use of antipsychotic medications, and non-pharmacological interventions were not developed or implemented prior to the administration of these drugs. Staff interviews and record reviews revealed that the resident began experiencing increased sedation, weight loss, decreased ability to communicate, and multiple falls after the initiation of the psychotropic medications. Documentation showed that Haldol was administered even after the resident was no longer agitated, and there was a lack of evidence that non-pharmacological interventions were attempted before resorting to medication. Progress notes and medication administration records indicated that PRN Haldol was given multiple times without proper documentation of the behaviors leading to its use or the effectiveness of alternative interventions. The resident's guardian was not adequately informed about medication changes, and consent forms lacked critical information such as dosage, route, frequency, and expected benefits or side effects. Observations and interviews with staff highlighted issues of short staffing, lack of individualized care, and insufficient monitoring of the resident's condition, including hydration and nutritional status. The resident was found to be lethargic, unable to eat or drink, and had significant weight loss and dehydration, ultimately requiring transfer to a hospital. The facility's interdisciplinary team and medical director were not fully aware of the extent of the psychotropic medication regimen, and there was a failure to ensure appropriate oversight and monitoring of the resident's response to these medications.
Removal Plan
- Obtain an order from the facility Psychiatrist/Resident's Physician to discontinue medication.
- Add 1:1 for safety of self and other residents due to increased aggression.
- Complete a chart audit on all residents currently prescribed an antipsychotic medication to ensure an adequate indication for use and appropriate documentation is present to support use of the medication.
- Audit all residents who receive antipsychotic medication.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three Certified Nursing Assistants (CNAs) who had been employed for more than 12 months. Personnel file reviews for these CNAs showed no evidence of annual performance evaluations within the past year. This was confirmed by both the Business Office Manager (BOM) and the Nursing Home Administrator (NHA), who acknowledged that the required evaluations had not been conducted or documented as per facility policy. Interviews with facility staff further confirmed the absence of these reviews, with the BOM stating that performance evaluations are expected annually and should be maintained in employee files. The facility's policy specifies that additional training should be provided based on areas of weakness identified in performance reviews, and that such education should be completed within 90 days of the appraisal. The lack of completed performance reviews resulted in the potential for unidentified performance concerns and unmet training needs for the CNAs involved.
Failure to Implement Effective QAPI Program and Address Dementia Care Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and corrected quality deficiencies, particularly in the dementia care unit. Interviews and record reviews revealed that the QAPI committee did not consistently review or analyze data, nor did it develop plans of action when concerns were identified. The QAPI plan document was incomplete, lacking essential information such as the facility name, vision, mission, and purpose. The Nursing Home Administrator, who served as the QAPI Coordinator, acknowledged that records of ongoing data review and analysis were limited, and necessary reports were not being generated due to significant management turnover. As a result, issues such as the use of psychotropic medications and staff training deficiencies were not adequately monitored or addressed. A resident with dementia did not receive individualized care despite interventions provided by her Durable Power of Attorney (DPOA) to reduce stress responses. Staff interviews indicated a lack of knowledge regarding effective interventions for this resident, and concerns raised by staff were not acted upon. The QAPI committee was aware of deficiencies in staff performance evaluations and training but did not implement a Performance Improvement Plan (PIP). The facility was unaware of non-compliance related to psychotropic medication use until it was identified during the survey.
Failure to Ensure Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director or their designee attended the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by facility policy. Review of QAPI committee sign-in sheets showed that neither the medical director nor a designee attended any meetings from April to August 2025. During an interview, the Nursing Home Administrator (NHA) stated that significant management turnover and a change in medical directors contributed to the lack of attendance, with the former medical director not attending as required and the new medical director missing meetings due to scheduling issues. Facility policy specifies that the QAPI committee must be interdisciplinary and include the medical director or designee, meeting at least quarterly.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members, as evidenced by interviews and record reviews. The Director of Nursing (DON) reported that the facility previously used a computer-based training platform, but after discontinuing the service, they lost access to records of completed staff training. There was no current staff training program in place, and any training that was completed was supposed to be recorded in employee files. However, a review of employee files for several CNAs revealed no documentation of training related to Quality Assurance and Performance Improvement (QAPI), Infection Control, Compliance and Ethics, Communication, or Resident Rights within the past 12 months. Further interviews with the Nursing Home Administrator (NHA) confirmed that the facility had not been tracking staff training and was aware that some training requirements had not been met. The NHA also stated that there was no Performance Improvement Plan in place to address the lack of annual staff training. A review of the facility's assessment indicated that the training program was supposed to include ongoing training for existing staff, covering topics such as effective communication, resident rights, infection control, QAPI, and compliance and ethics, but this was not being implemented as described.
Failure to Provide and Document Required CNA In-Service Training
Penalty
Summary
The facility failed to implement an effective in-service training program for nurse aides, specifically not supporting mandatory attendance, tracking participation, or ensuring continuing competence. Review of personnel files for three CNAs revealed that documentation did not reflect the required 12 hours of annual training. The Director of Nursing reported that the facility had been without a staff educator and that she was attempting to cover those responsibilities, but had not yet established a staff training plan. Additionally, the facility had discontinued use of a computer-based training system and could not access previous staff training records. The Business Office Manager confirmed that the personnel files for the reviewed CNAs lacked evidence of the required annual training. The Nursing Home Administrator acknowledged awareness of the non-compliance with the 12-hour annual training requirement and confirmed that there was no current staff training plan in place. These findings indicate that the facility did not maintain an appropriate and effective nurse aide in-service training program as required by policy.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions for a resident diagnosed with vascular dementia and severe cognitive impairment. The resident exhibited behaviors such as wandering, disorientation, emotional frustration, and stress, but the care plan did not accurately reflect the resident's needs or preferences. The care plan included an incorrect nickname, omitted specific non-pharmacological interventions suggested by the resident's DPOA, and did not address known triggers or effective calming techniques such as gentle handling of the resident's hands or back rubs. Additionally, the care plan did not document the resident's preference for napping after breakfast, which was known to reduce agitation. Observations revealed that the resident spent extended periods in bed with no access to preferred items such as a radio, books, or magazines, and the call light was out of reach. The activity attendance log showed minimal participation in sensory stimulation activities, and interviews with staff indicated a lack of knowledge about the resident's preferences and effective interventions. Staff members, including LPNs and activity assistants, reported not receiving dementia care training and expressed difficulty in managing the resident's behaviors. The resident's DPOA and guardian reported that their input regarding triggers and calming strategies was not incorporated into the care plan or daily care practices. The facility's dementia care policy required individualized, person-centered care and staff training, but these standards were not met. There were no planned activities for men or for residents on the locked dementia unit after certain hours, and staffing levels were insufficient to provide appropriate care and activities, especially in the evenings. Staff interviews confirmed that residents with dementia were not receiving adequate attention, activities, or individualized interventions, contributing to ongoing behavioral issues and emotional distress for the resident.
Inaccurate Medical Record Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and complications from a stroke. The resident's care plan inaccurately listed a nickname that was not used by the resident, and the Durable Power of Attorney (DPOA) confirmed that using this nickname would cause confusion. The DPOA also stated that the resident could not participate in traditional leisure activities and had not attended any outings, which would have required her permission. Multiple staff interviews corroborated that the resident did not participate in group activities due to cognitive deficits. Despite this, the activity attendance record documented the resident as having participated in various group activities and outings, including after the resident had already been discharged to an acute care setting. The Activity Director acknowledged that some activities recorded, such as self-propelling a wheelchair or looking out a window, did not meet the definition of leisure activities and confirmed that outings were not offered by the facility. The Activity Director also noted that the activity assistant responsible for documentation had difficulty accurately recording attendance, likely resulting in erroneous entries. These inaccuracies resulted in a medical record that was not factual, accurate, complete, or current.
Failure to Provide Resident-Centered Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide resident-centered activities designed to support the leisure needs of a resident with severe cognitive and visual impairments. The resident, who had diagnoses including vascular dementia with behavioral disturbances, adjustment disorder, and sequelae of cerebral infarction, was assessed as severely cognitively impaired and highly visually impaired. Documentation indicated that the resident was dependent on staff for mobility and unable to participate in traditional leisure activities due to these deficits. Despite this, the activity attendance log showed minimal participation in sensory stimulation and inaccurately documented independent engagement in activities such as religious study and jigsaw puzzles, which the resident's durable power of attorney (DPOA) and staff interviews confirmed were not possible due to the resident's limitations and lack of interest. Interviews with the DPOA revealed that staff never consulted her regarding the resident's past leisure interests, and she stated the resident could not accurately express his preferences. The DPOA also reported that the resident could not engage in activities like reading, puzzles, or watching television, and that religion was not important to him, contradicting the activity records. Staff interviews further confirmed that the resident required one-on-one assistance for any leisure activity and was rarely observed participating in any activities. The activity assistant reported not being informed of the resident's preferences and resorted to placing various supplies in front of the resident to gauge interest, but noted the resident appeared emotionally distressed and unable to participate in group activities. Additional interviews with facility staff, including the activity director and former social services director, highlighted concerns about the quality and quantity of individualized activities offered in the memory care unit. The activity director acknowledged that documentation of self-propelling a wheelchair or looking out the window was inaccurately recorded as leisure activity participation. The nursing home administrator confirmed awareness of the need for more individualized activities in the memory care setting, as current practices did not adequately address the resident's needs for meaningful engagement.
Call Light Accessibility Not Ensured for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident who was severely cognitively impaired and required assistance with most activities of daily living, as documented in the Minimum Data Set. Multiple observations showed that the resident's soft-touch call light was either under the sheet at waist level or clipped to the fitted sheet at the head of the bed, both out of the resident's sight and reach. During interviews, the unit manager acknowledged that the call light should have been accessible and explained that staff placed it under the sheet so the resident might activate it by rolling onto it, but confirmed that staff should not have done this.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that a resident in need of dialysis received care and services that met safety and appropriateness standards. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Unattended Narcotic Medication Left on Medication Cart
Penalty
Summary
A narcotic medication, specifically Lorazepam, was observed left unattended in a plastic medication cup on top of a medication cart in the common area of the secure unit. The cup, labeled with a resident's name and containing a white substance submerged in liquid, was left next to a plastic drinking cup of tan colored liquid. This situation occurred while there were seven residents present in the room, including one resident who was ambulatory, and a CNA who was not monitoring the medication cart. The medication and supplement remained unattended and out of staff line of sight for a total of 37 minutes, during which time staff and visitors moved in and out of the area. Interviews with staff confirmed that the assigned nurse, RN R, had left the medication unattended while off the unit for approximately 15 minutes. RN R acknowledged the medication was a prescription narcotic intended for a resident present in the area and admitted it should not have been left unattended. Additional staff interviews and review of facility policy confirmed that medications, especially controlled substances, are required to be under direct observation or locked at all times. The facility's policy also specifies that all drugs and biologicals must be stored in locked compartments, and controlled substances must be double-locked, which was not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Gait Belt Use and Wheelchair Footrest Safety
Penalty
Summary
The facility failed to ensure proper accident prevention measures were implemented for two residents. For one resident with a history of muscle weakness and a displaced intertrochanteric fracture of the left femur, a Physical Therapy Assistant (PTA) was observed assisting her to ambulate in the hallway without the use of a gait belt. Multiple staff interviews, including those with the Therapy Director, Certified Nurse Assistants, and the Director of Nursing, confirmed that facility policy and staff orientation require the use of a gait belt when assisting any resident with ambulation in the hallway, regardless of their independence in their room. The resident's care plan indicated a need for supervision and assistance with ambulation due to a history of falls and weakness, but the intervention was not followed during the observed event. In a separate incident, another resident with Alzheimer's disease, muscle weakness, and severe cognitive impairment was transported in a wheelchair by a Physical Therapist without footrests in place. The therapist was observed pushing the resident down the hallway, then leaving her unattended to retrieve the footrests, during which time the resident placed her feet on the floor. Staff interviews confirmed that the expectation is for footrests to be in place whenever a resident is transported in a wheelchair. Both incidents demonstrate a failure to follow established safety protocols for ambulation and wheelchair transport, as observed and confirmed by staff and record review.
Inadequate Time and Oversight for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was dedicated at least part-time to the infection prevention and control program, and that the IP was provided sufficient time to fulfill the responsibilities of the role. The individual assigned as IP was also serving as the Assistant Director of Nursing (ADON) and, more recently, as the Unit Manager (UM) for the rehab unit. This staff member reported being pulled to cover open shifts on the floor, being on call, and handling additional administrative and clinical duties, which significantly limited the time available for infection control tasks. The IP estimated spending only about 3 hours per week on infection control, despite stating that 20 to 25 hours per week would be appropriate for the role. Interviews and record reviews revealed that the IP's infection control activities were limited, with audits focusing only on the availability of gowns and gloves rather than staff compliance with personal protective equipment (PPE) use. The IP acknowledged that staff were not compliant with PPE requirements for residents on Enhanced Barrier Precautions (EBP) and that there had been insufficient time to reeducate staff on proper PPE use. The last infection control education provided to staff was several months prior, and the IP had only recently completed uploading resident immunization data from the previous fall. The facility's own assessment and job descriptions indicated that the IP role was intended to be a distinct responsibility, but in practice, it was combined with multiple other roles, resulting in inadequate oversight and management of the infection prevention and control program.
Inadequate Dietary Management Leads to Disrupted Meal Service
Penalty
Summary
The facility failed to ensure that the dietary manager had the necessary competencies and skill set to manage the food and nutrition service, resulting in the potential for unmet nutrition and hydration needs for all residents dependent on the facility kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, consisting only of milk, eggs, and a few loaves of bread, and that menu items could not be served as planned due to missing ingredients. Staff described having to use emergency food supplies, which were not replenished, and substituting menu items due to lack of availability. There was also a reported shortage of thickened juice required for therapeutic diets, and staff were unclear about when the dietary manager or interim manager would be present, as both were PRN and not full-time. Further interviews revealed confusion and lack of oversight in the ordering process, with the interim dietary manager admitting to not knowing how to place food orders and relying on training that had not yet occurred. The registered dietitian clarified that she was not overseeing daily kitchen operations and would not be present daily, despite being named as the full-time dietitian. The previous dietary manager confirmed she was no longer responsible for the kitchen and had only briefly assisted with food ordering. Observations also noted expired food items in the kitchen. These findings demonstrate a lack of competent and consistent management in the dietary department, leading to disruptions in meal service and potential unmet nutritional needs for residents.
Failure to Follow Menus and Obtain Dietitian Approval for Substitutions
Penalty
Summary
The facility failed to follow its planned menus, resulting in the potential for inadequate nutritional value and unmet nutritional needs for all residents consuming food from the kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, providing only milk, eggs, and bread, and that there was not enough of certain items, such as bread and bacon, to fulfill the menu requirements. Staff described having to make unapproved substitutions, such as serving scrambled eggs and toast instead of sausage gravy and biscuits, and using ham in place of pot roast because the latter was not thawed. The dietary staff indicated that they often had to be creative with meal preparation due to unavailable menu items, and that the dietary manager or interim manager, both PRN staff, were responsible for approving substitutions, though their presence in the facility was inconsistent. Further investigation revealed that the registered dietitian had not been notified of menu substitutions and had not visited the facility during the relevant period. The dietitian confirmed she had not approved any substitutions or signed off on a substitution log, as required. Staff interviews indicated a lack of awareness or use of a substitution log, and the dietary manager was not present to oversee or document menu changes. The administrator reported that some food items, such as sausage gravy, were unusable due to damage, necessitating substitutions that were not properly communicated or documented. This lack of adherence to menu planning and required oversight by the dietitian led to the cited deficiency.
Failure to Ensure PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP), as observed with two residents who had indwelling medical devices. One resident, who was severely cognitively impaired and had a Foley catheter, was not care planned for EBP and was observed being assisted by staff without the use of gown or gloves during care activities. Interviews with nursing staff and leadership confirmed that EBP should have been implemented for this resident, and that staff were expected to use PPE during care, but this was not followed in practice. Another resident, also severely cognitively impaired and with a gastrostomy tube, had signage indicating EBP and orders specifying the use of gown and gloves for high-contact care activities. Despite this, staff were observed providing care, such as adjusting linens and assisting with transfers, without donning PPE. Interviews revealed confusion among staff regarding the need for EBP, with some staff unaware that the resident was on EBP or misunderstanding when PPE was required. The infection preventionist acknowledged that staff were noncompliant with PPE use despite education and posted signage. Review of facility policy and CDC guidance confirmed that residents with indwelling medical devices require EBP during high-contact care activities, and that monitoring of staff adherence was expected. However, observations and staff interviews demonstrated a lack of compliance with these requirements, resulting in a failure to implement the infection prevention and control program as intended for residents at risk.
Failure to Develop Person-Centered Care Plan for Foley Catheter and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a person-centered care plan that accurately reflected the current care needs of a resident with severe cognitive impairment and a history of psychotic disorder with delusions and dementia with behavioral disturbances. The resident was observed with a Foley catheter in place, and medical orders indicated the need for regular assessment of catheter patency. However, the care plan only addressed fall risk related to incontinence and the use of a Foley catheter for urinary retention, without including any focus, goals, or interventions for enhanced barrier precautions associated with the presence of the catheter. Interviews with facility staff, including the ADON/Unit Manager/Infection Preventionist, LPN Supervisor, and DON, confirmed that enhanced barrier precautions should have been implemented and care planned for any resident with a Foley catheter. Staff acknowledged that the resident did not have a care plan in place for enhanced barrier precautions, despite the presence of the catheter and the facility's expectations and protocols. This omission resulted in an inaccurate reflection of the resident's current care needs and the potential for unmet care needs.
Failure to Update Resident Care Plan for Dietary and Hydration Needs
Penalty
Summary
The facility failed to revise and maintain an accurate, person-centered care plan for a resident with a history of traumatic subdural hemorrhage and severe cognitive impairment. The resident's diet and hydration needs had changed, including advancement of diet and discontinuation of G-tube feedings, but the care plan continued to reflect outdated interventions such as a pureed diet and nectar thick liquids. Observations and interviews revealed that visual cues and current orders indicated the resident was on a mechanical soft diet with honey thick liquids, but these changes were not reflected in the care plan. Multiple staff interviews confirmed that the care plan had not been updated to match the resident's current needs, and there was confusion regarding responsibility for updating the care plan due to the absence of a dietary manager and changes in unit management. The deficiency was identified through review of records, staff interviews, and direct observation, which showed discrepancies between the resident's current dietary orders, visual staff cues, and the documented care plan. The care plan was not revised in a timely manner to reflect the resident's current nutritional and hydration requirements, resulting in an inaccurate and incomplete description of the resident's care needs. This failure created the potential for unmet care needs due to staff relying on outdated care plan information.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled activities of daily living (ADL) care, specifically showers, to dependent residents who required assistance. Two residents with significant physical disabilities and cognitive intactness reported not receiving showers as scheduled, with one resident going up to a week and a half without a shower and another going about nine days without one. Review of facility records confirmed gaps in shower documentation, with periods of 7 to 12 days between documented showers for both residents. There were no documented refusals for showers during these periods, and the residents' care plans indicated they were to receive showers twice weekly on specific days. Interviews with staff revealed that showers were often missed during busy or understaffed shifts, with CNAs prioritizing other tasks such as passing dinner trays, feeding residents, and putting residents to bed. Staff reported that showers were documented only on shower sheets, which were then signed off by nurses, and that refusals were to be documented in progress notes. The Director of Nursing confirmed that short staffing was not an acceptable reason to skip scheduled showers and that the standard of care was two showers per week. Despite these expectations, the facility did not ensure that dependent residents consistently received their scheduled showers.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for three residents, resulting in multiple incidents. One resident with severe cognitive impairment and a history of psychotic disorder and dementia was involved in repeated altercations with another resident who was moderately cognitively impaired and had a history of behavioral disturbances. These altercations included verbal aggression, physical contact, and spitting. Despite these incidents, there were no specific interventions documented or implemented to address the ongoing conflict between the two residents, and staff were largely unaware of any required actions to prevent further incidents. Behavior logs and care plans lacked updates or targeted interventions following the altercations, and incident reports were not consistently completed or documented in progress notes. Another resident, who was severely cognitively impaired and identified as an elopement risk due to a traumatic brain injury, was able to exit the building unsupervised. Although the care plan indicated the need for one-to-one supervision during waking hours, this intervention was not consistently implemented due to staffing challenges. On the night of the elopement, the resident was left unsupervised when the assigned CNA was attending to other residents, and the facility's front door was found to be unlocked, allowing the resident to leave the premises. Staff interviews confirmed that one-to-one supervision was difficult to maintain and that the door security was not consistently enforced prior to the incident. Facility policies required the identification of hazards, implementation of targeted interventions, and communication of these interventions to all relevant staff. However, the report shows that interventions were not effectively communicated or consistently put into action. Staff members, including CNAs, nurses, and the social services director, were either unaware of or did not implement new interventions following incidents. Documentation was incomplete or missing regarding both the altercations and the elopement, and the required supervision and environmental controls were not reliably maintained.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, which increased the potential for contamination and decreased resident satisfaction. During a kitchen tour, it was observed that the three-compartment sink and the one-compartment sink on the preparation table were directly connected to the wastewater drain without an air gap, contrary to the 2022 FDA Food Code. The Certified Dietary Manager indicated that the one-compartment sink was used for discarding ice and water from canned goods, and there was no preparation sink available for thawing products. Additionally, the Riverside Spa room was missing a light shield on one of the light ballasts, posing a risk of broken glass contamination. Further observations revealed multiple cleanliness and maintenance issues throughout the facility. Resident rooms had chipping paint and scratches, and the TV/Brief room had storage racks made of raw wood, which were not easily cleanable and showed dark staining. The Meadowlane dining room had lounge chairs with debris accumulation, including trash and food spills. The central supply room and laundry room had raw wood shelves and missing light shields, respectively. The beauty shop lacked an in-line atmospheric vacuum breaker on the hair spray rinse sink, increasing the risk to the potable water supply. Housekeeping staff shortages were noted, affecting the cleanliness of the memory care unit.
Failure to Provide Annual Abuse Prevention Training
Penalty
Summary
The facility failed to provide the required annual abuse prevention education for all employees, which has the potential to affect all 73 residents residing in the facility. The Assistant Director of Nursing (ADON) was unaware of her responsibility for training employee education and did not have access to the electronic training program to track education completion. The Director of Nursing (DON) reported that the facility previously used an electronic training program owned by the facility's previous owners, but the new owners did not continue the contract, leading to a lack of assigned trainings. The facility's assessment and employee training records revealed that 91 out of 128 staff members did not receive the required annual abuse prevention training. The facility's policy on abuse, neglect, and exploitation outlined the need for new employees to be educated during initial orientation and for existing staff to receive annual education through planned in-services. However, the facility was unable to provide evidence of compliance with this policy, resulting in a deficiency noted by the surveyors.
Failure to Implement Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program specifically targeting the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an observation, it was noted that the facility was in the process of removing unused hoppers and stagnant lines, but there was no evidence of a systematic approach to flushing minimal use or unused fixtures. The Maintenance Director (MD) Z indicated that water samples for legionella had not been tested in a year or two, and there were no current sampling activities for any pathogens. Further investigation revealed that the facility's Water Management Plan (WMP) was not being implemented as designed. The plan required specific control measures to be applied, monitored, and documented, but none of these actions were being carried out. MD Z was unable to confirm whether control measures were in place to reduce the risk of legionella or OPPP, and there was uncertainty about the status of water lines in the Meadowlane Spa room. The lack of documentation and tracking of control measures as outlined in the WMP contributed to the deficiency.
Excessive Hot Water Temperatures Pose Scalding Risk
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F, which increased the risk of injury among residents. During a tour of the Riverside Spa, the hot water from the hand sink was found to reach 123°F, as measured by a Thermoworks rapid read digital thermometer. The Maintenance Director (MD Z) stated that the usual hot water temperatures range from 116°F to 118°F. In the boiler room, the boiler was set at 140°F, and the domestic hot water flowed through a thermostatic mixing valve, showing an outgoing temperature of 125°F. MD Z confirmed that there were no other hot water systems in the building and that the kitchen and laundry received hot water directly from this source before it was mixed down. He also mentioned that he typically takes hot water temperatures in the morning. Further observations revealed that the hot water temperature in the Meadowlane Spa reached 135°F, and a Certified Nursing Assistant (CNA I) noted that staff generally turn the water on as hot as it will go and then dial it back for residents. Additional observations in shared bathrooms between resident rooms showed hot water temperatures ranging from 128°F to 134°F. In the Valley Court Spa, the hot water in the sink reached 135°F, and the shower reached 126°F. The surveyor informed the Assistant Director of Nursing (ADON E) about the excess hot water temperatures and the increased concern for resident harm due to scalding and burning. A subsequent review of the Valley Court Spa room found the hot water from the sink reached 118°F.
Failure to Maintain Nebulizer Equipment for Resident with COPD
Penalty
Summary
The facility failed to maintain nebulizer equipment for a resident with chronic obstructive pulmonary disease (COPD), leading to potential risks of inconsistent equipment exchange, irregular cleaning, and respiratory infection. Observations over several days revealed that the nebulizer machine and tubing were left on the bedside dresser without a storage bag, and the tubing was dated from nearly a month prior. The resident, who was cognitively intact, reported uncertainty about the last use of the nebulizer. Physician orders indicated the resident required nebulizer treatments as needed for wheezing or shortness of breath. Interviews with nursing staff confirmed that oxygen supplies, including nebulizer kits, were supposed to be changed weekly and stored properly when not in use. However, the nebulizer kit at the resident's bedside was outdated and used during an episode of severe respiratory distress, after which the resident was transferred to an acute care setting. The facility's policy required nebulizer tubing and delivery devices to be changed every 72 hours or as needed if soiled or contaminated, and to be kept in a plastic bag when not in use.
Failure to Obtain COVID-19 Vaccination Consents
Penalty
Summary
The facility failed to obtain COVID-19 vaccination consents or declinations for two residents, leading to a deficiency in ensuring that residents or their representatives were informed about the vaccination and its associated risks and benefits. Resident #44, who was severely cognitively impaired with a BIMS score of 6, received a Pfizer Booster without any record of her dual POAs being contacted for consent. This oversight resulted in the resident's representatives being unaware of the vaccination and the risks/benefits involved. Resident #37, who was cognitively intact with a BIMS score of 15, refused the Moderna Booster, but the facility did not provide a consent or declination form that included the risks and benefits of the vaccine. The Assistant Director of Nursing, who also serves as the Infection Preventionist, acknowledged that the correct COVID-19 consent forms were not available until the end of October, which contributed to the failure in obtaining proper documentation. The facility's COVID-19 Vaccination policy required that residents or their representatives sign a consent form prior to vaccination, but this was not adhered to in these cases.
Improper Transfer Documentation and Notification
Penalty
Summary
The facility failed to provide proper documentation and notification regarding the transfer or discharge of residents, specifically for two residents. Resident #72, who had a traumatic hemorrhage of the cerebrum and a non-displaced fracture of the seventh cervical vertebra, was discharged to home by choice. However, the facility incorrectly used an involuntary transfer form, which was not appropriate since the discharge was resident-initiated. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Work Director (SWD) revealed confusion and miscommunication regarding the correct forms and procedures for resident-initiated discharges. Additionally, the facility failed to notify the local ombudsman of resident transfers, as required. None of the staff, including the Nursing Home Administrator (NHA), DON, ADON, or SWD, took responsibility for providing the monthly transfer notice list to the ombudsman's office. This lack of communication and responsibility resulted in the ombudsman not receiving the necessary notifications. Furthermore, for Resident #40, who had Alzheimer's disease and other significant health issues, the facility used an incomplete involuntary transfer form when the resident was sent to the ER after a fall, failing to document the destination and reason for the transfer.
Care Plan Deficiencies in Fall Prevention and Contracture Management
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in fall prevention and contracture management. Resident #225, who has paraplegia, was identified as a low risk for falls, but after a fall incident on 11/2/24, it was determined that a bolster should be used to prevent future falls. However, this intervention was not added to the resident's care plan or Kardex, despite the resident's tendency to stay close to the edge of the bed. Observations confirmed the bolster was in use, but the care plan was not updated to reflect this necessary intervention. Resident #35, diagnosed with Alzheimer's disease, dementia, and a contracture of the right hand, had a care plan that included the use of a soft hand splint. However, the physician's order to discontinue the splint was not reflected in the care plan, leading to confusion among staff. Observations showed the resident was not wearing the splint, and interviews with staff confirmed the order had been discontinued, yet the care plan still indicated its use. This discrepancy was only corrected after the surveyor's review.
Deficiency in Behavioral Health and Dementia Training
Penalty
Summary
The facility failed to provide adequate training for behavioral health care and dementia to its staff, as required by the facility assessment. During interviews, the Assistant Director of Nursing (ADON) was unaware of her responsibility for employee education and lacked access to the electronic training program to track education completion. The Director of Nursing (DON) reported that the facility previously used an electronic training program owned by the previous owners, but the new owners did not continue the contract, leading to a reliance on in-person education and scheduled in-services. A review of the facility's employee training records revealed that 68 out of 128 staff members did not receive the required annual behavioral management and dementia training before the survey began. The facility assessment, reviewed with the Quality Assessment and Assurance (QAA) Committee, outlined the services and care offered based on residents' needs, including behavioral and mental health management. However, the facility was unable to provide evidence of compliance with these training requirements, resulting in a deficiency report.
Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to immediately report an elopement incident involving a resident with severe cognitive impairment and did not submit an investigation report to the State Agency within the required 5-day period. The resident, who was at high risk for elopement due to conditions such as unspecified dementia and cognitive communication deficit, was found unsupervised in the facility's parking lot. Despite the resident's cognitive impairments and lack of authorization to leave the facility, the incident was not reported as an elopement, and no investigation was conducted. Interviews with staff revealed that the resident was seen walking alone outside the facility by an LPN, who reported the situation to a CNA. The CNA then informed an RN, who found the resident in the parking lot looking for his car and wife. The resident was disoriented and had a history of wandering and falls, making it unsafe for him to be outside unsupervised. The Director of Nursing acknowledged that the resident did not have authorization to leave the building alone, and the Medical Director confirmed that no medical authorization was given for the resident to exit the facility unsupervised.
Failure to Develop Elopement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was at high risk for elopement, resulting in the resident exiting the building unsupervised. The resident, who was severely cognitively impaired with a BIMS score of 3/15, had a history of delusions, used a wheelchair for mobility, and was at high risk for falls due to conditions such as unspecified dementia and osteopenia. Despite these risks, the care plan did not include any focus, goal, or interventions related to the resident's risk for elopement. On a specific occasion, the resident was found standing in the parking lot, confused and lost, indicating an elopement incident. Interviews with facility staff revealed that the resident frequently wandered and expressed a desire to leave, yet no specific care plan interventions were in place to address the risk of elopement. The Nursing Supervisor confirmed that the resident's high-risk elopement assessment should have prompted the development of a person-centered care plan to mitigate the risk of elopement.
Deficiencies in Safety Protocols and Equipment Maintenance
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards, resulting in an elopement incident involving a resident with severe cognitive impairment. The resident, who was at high risk for elopement, was found unsupervised in the parking lot after leaving the facility through unlocked lobby doors. Despite being identified as a high elopement risk, the resident's care plan did not address this risk, and the facility did not follow its own elopement protocol, failing to conduct a head count, assess the resident for injuries, or notify the resident's power of attorney. Another incident involved a resident who suffered a head laceration after falling from a mechanical lift that had not been properly maintained. The lift's hanger bar disconnected from the boom due to a loose screw, causing the resident to fall. The facility's maintenance program lacked a schedule for routine preventative maintenance on nursing equipment, and the Director of Maintenance admitted that no such maintenance had been performed in over a year. The facility also lacked an inventory system for nursing equipment and user manuals, further contributing to the failure to maintain the lift properly. Interviews with staff revealed a lack of communication and responsibility regarding equipment maintenance and elopement protocols. The Director of Nursing and other staff members were unaware of the necessary steps to prevent and respond to elopements, and the maintenance department did not have a system in place to ensure regular equipment checks. These deficiencies highlight significant lapses in the facility's safety protocols and preventative maintenance practices, leading to potential harm to residents.
Failure to Assess Change of Condition and Provide Wound Care
Penalty
Summary
The facility failed to assess an acute change of condition in one resident and failed to provide appropriate skin care for another. One resident, who had severe cognitive impairment and was on droplet isolation for COVID-19 exposure, experienced a significant decline in condition. Despite multiple reports from CNAs about the resident's deteriorating state, the assigned LPN did not perform an assessment or notify the physician in a timely manner. The resident was eventually sent to the hospital after family intervention, where she was diagnosed with severe dehydration, hypernatremia, and a urinary tract infection, conditions that were not identified or treated by the facility staff in a timely manner. Another resident, who also had severe cognitive impairment, suffered from multiple skin tears and abrasions. The facility failed to follow physician orders for wound care, resulting in inconsistent and inadequate treatment. Observations revealed that the resident had dressings on both shins that were not documented in the medical records, and the prescribed treatments were not administered as ordered. This lack of proper documentation and adherence to treatment protocols increased the risk of infection and further complications for the resident. Interviews with staff members highlighted a lack of communication and proper response to changes in residents' conditions. The LPN responsible for the first resident did not take appropriate actions despite being informed of the resident's worsening state by multiple CNAs. Similarly, the wound care for the second resident was not managed according to the physician's orders, indicating a systemic issue in the facility's ability to provide adequate care and documentation for its residents.
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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.
Surveyors found that multiple dependent residents did not receive consistent bathing, hair washing, shaving, or oral hygiene as required by their care plans and ADL needs. One resident with COPD, dementia, and a colostomy went at least 30 days without a documented shower or hair wash and was repeatedly observed with long chin hair despite stating she preferred it shaved. Another hospice resident’s showers and baths were provided only by hospice staff, with no evidence that facility CNAs delivered or documented any bathing during the review period, and hospice documentation was not incorporated into the facility record. A third resident with hemiplegia and major depression was observed with heavy facial hair and plaque on her teeth, reported concerns about shared razors, and had an unused personal electric shaver at bedside, while shower sheets showed no showers or bed baths in 30 days and only two documented refusals without evidence of re-approach or nurse notification.
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.
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 Provide and Document Basic ADL Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document basic activities of daily living (ADL) care, including bathing, hair washing, shaving, and oral hygiene, for multiple dependent residents. One resident with COPD, dementia, colon cancer with colostomy, anxiety, and depression required substantial to maximal assistance with showering, personal care, toileting, dressing, and transfers per the MDS and care plan. This resident reported that staff only sometimes shaved her facial hair and confirmed she preferred to have her chin shaved, yet surveyors repeatedly observed long chin hairs over several days. Review of the care plan showed she needed physical assistance with personal hygiene and that staff often needed to shave whiskers on her chin. Task sheets and shower documentation revealed no recorded bath or hair wash in the last 30 days, and two shower sheets within that period documented that she was not shaved on either shower day, with no explanation for missed showers or refusals. Further interviews and record reviews showed systemic documentation and scheduling issues contributing to the lack of care. A CNA stated the resident was scheduled for showers twice weekly and that refusals were to be documented on shower sheets and escalated to the nurse, but the facility could not produce adequate shower documentation for the prior 30 days. The DON later explained that CNAs did not know how to enter PRN showers and that when the resident was moved from one bed to another months earlier, her shower task days were not updated, leading CNAs to mark “NA” and follow an outdated schedule. The DON acknowledged that the resident had been moved in June of the prior year and that staff had continued to rely on the old schedule, and also acknowledged that no one had noticed the resident was not receiving showers as ordered. Another resident on hospice services, who was dependent on staff for all ADLs, also did not receive showers or baths from facility CNAs during the review period. Hospice coordination notes showed that a hospice CNA provided showers or baths on several specific dates, but there was no documentation that facility CNAs provided any showers or baths or documented refusals during the last 30 days. The DON stated that hospice admission information and visit notes were sent to the business office and ward clerk and were expected to be scanned into the electronic record or placed in a hospice binder, but record review revealed no hospice documentation in the electronic medical record or paper chart. The hospice binder was instead sitting in someone’s email account, and the DON stated she expected facility CNAs to provide care regardless of hospice involvement. A third resident with hemiplegia, muscle disorder, cervical disc disorder, fistula, difficulty walking, and major depression was dependent for all ADLs and was observed with visible plaque buildup on her teeth and heavy facial hair on her chin and upper lip. She reported that she had asked staff to shave her facial hair but was told the same razor was used on multiple residents, leading her to refuse that method and have her husband bring in an electric razor, which remained unused on her overbed table for at least a day. A CNA confirmed that the resident had not had her facial hair shaved until that point and that she was scheduled for a bed bath that day. The care plan directed staff to shave her face as needed and to encourage her to allow shaving, and there was no care plan entry stating she did not want her facial hair shaved. Shower sheets listed her for showers/bed baths twice weekly, but documentation showed no showers or bed baths in the last 30 days, with only two dates marked as refusals and no evidence of re-approach or nurse notification. The DON stated the expectation was twice-weekly showers or bed baths and acknowledged that refusals were only documented on two dates, with no corresponding progress notes showing re-approach or nurse follow-up, aside from a single progress note where the resident refused shaving with no documented follow-up.
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.
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