The Springs At Rochester Hills Rehab And Nursing C
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester Hills, Michigan.
- Location
- 1480 Walton Blvd, Rochester Hills, Michigan 48309
- CMS Provider Number
- 235036
- Inspections on file
- 29
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at The Springs At Rochester Hills Rehab And Nursing C during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and significant psychiatric and medical histories were involved in a resident‑to‑resident assault when a wheelchair user appeared to roll over an ambulatory resident’s foot, after which the ambulatory resident intentionally punched the wheelchair user in the nose with a closed fist. Witnesses, including a CNA and an LPN, reported the punch, the aggressor’s statement that he “meant to do it,” and immediate nasal bleeding and distress, and the aggressor later admitted to staff and law enforcement that he struck the other resident. The injured resident, who had dementia, bipolar disorder, prior brain bleed, and was on hospice, sustained bilateral nasal fractures, experienced 10/10 pain requiring PRN analgesics, showed anxiety and agitation, and later reported ongoing head and ear pain, bruising, and feeling unsafe. Records showed the aggressor had previously assaulted another female resident with a closed fist, and the facility’s abuse policy defined such willful hitting as abuse and required protection and care plan revision after abuse; however, the facility’s investigation did not verify abuse and the injured resident’s care plan was not updated to address protection or psychosocial needs following the incident.
The facility failed to maintain a comfortable, homelike environment by not ensuring consistent availability of towels, washcloths, and personal clothing for multiple residents. CNAs reported chronic linen shortages, starting some shifts with no linens and resorting to using cut bath blankets, pillowcases, wipes, and draw sheets for hygiene care. Several residents stated they were not provided towels or washcloths, had to wait to be cleaned while staff searched for linens, or had to "fight" for scheduled showers. Observations of clean utility rooms showed minimal or no towels and washcloths, and some residents’ rooms lacked any linens or personal clothing, as confirmed by family members and staff. At the same time, surveyors discovered large quantities of new towels and washcloths stored unopened on a closed construction unit inaccessible to floor staff. The housekeeping and laundry staff cited being short-handed and lacking a clear system, and the facility had no written linen or laundry policy addressing how linens and residents’ clothing should be laundered and distributed.
The facility failed to provide adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one case, a resident with severe cognitive impairment and a history of aggression was heard yelling at another resident and was then observed kicking that resident while they were on the floor in his room, causing minor injuries and pain. In another case, staff placed two residents together as roommates despite staff concerns about one resident’s known aggressive behavior and dislike of roommates; shortly after the move, the other resident reported being hit and expressed feeling unsafe in that room. Additional incidents involved a resident who did not like others entering his room physically engaging with a resident who frequently climbed into other residents’ beds, and a separate hallway altercation where two cognitively impaired residents struck each other after one accused the other of stealing. These events occurred despite a written staffing policy stating that adequate licensed nursing and CNA coverage would be maintained to meet residents’ needs and provide necessary supervision.
The facility failed to consistently provide and offer evening and HS snacks as required by its own policy. A bedbound, oriented resident reported never being offered facility snacks and relying on family-provided food, while another oriented resident in a wheelchair stated they often missed evening snacks because they had to be at the nurses’ station at the right time and some days received no snack despite wanting one daily. A nonverbal resident’s family member reported the resident appeared hungry at night, requested double portions that were often not received, and had not been offered a grievance form. The Dietary Manager stated that various snacks were prepared and sent to the unit but acknowledged that snacks disappeared quickly, possibly due to residents hoarding them or staff taking them, and snacks were also kept in the dietary office. These observations and interviews showed that snacks were not reliably offered or made accessible to all residents in line with facility policy.
Multiple residents reported prolonged waits, often an hour or more, for toileting, incontinence care, transfers, water, and medications, with one bedbound resident describing inadequate perineal care that left stool caked on until morning and another bedbound resident waiting 1–2 hours for brief changes after using the call light. Two alert, oriented residents using wheelchairs stated they frequently waited in bed for assistance with bathroom needs and medications, while a family member repeatedly found their relative soaked in urine during visits. CNAs reported that when only two aides were assigned per floor of about 40 residents, especially on the night shift, they could not complete two-hour check-and-change care or timely feeding, and staffing records confirmed multiple nights with only two aides despite many residents requiring lift assistance, contrary to the facility’s own policy to maintain adequate staffing to meet resident needs.
Surveyors found that the facility did not consistently provide meaningful, person-centered activities as posted on the activity calendar. Two residents reported that scheduled activities such as BINGO and brain games, especially on weekends, were frequently missed or started very late, that music did not match their preferences, that room visits were not occurring, and that they were often not included in community outings. Observations confirmed that a scheduled BINGO session did not begin at the posted time, leaving residents waiting without explanation, and that some weekend and Sunday activities were not occurring despite being listed. Activity logs showed gaps in documented activities, no refusals, and minimal Sunday programming, while the Activity Director acknowledged late and missed activities and difficulty covering simultaneous activities on multiple floors with limited staff.
Multiple incidents of resident-to-resident physical abuse occurred, including one resident punching another and breaking her jaw, and another incident where a resident was pushed to the floor, kicked, and struck with a wheelchair. Staff witness statements and medical records documented more severe injuries and aggression than what was reported to the State Agency. Some staff did not report observed abuse incidents, and there were discrepancies between internal documentation and official reports, indicating a failure to accurately document and respond to abuse as required by facility policy.
The facility did not ensure timely and accurate reporting of suspected abuse incidents involving multiple residents, with staff failing to promptly notify authorities and accurately document the extent of injuries. A nurse admitted to not reporting all observed altercations and lacked training on abuse protocols, while the Administrator delayed reporting based on incomplete information. The facility could not provide evidence that all staff had received required abuse reporting education.
Insufficient nursing staff resulted in residents not receiving water for two days, incorrect meal tray delivery, lack of supervision for residents with dementia who wandered into other rooms, and staff confusion about assignments. Multiple residents with cognitive impairments were affected, and staff interviews confirmed delays in basic care due to heavy workloads and unclear responsibilities.
Facility administration did not follow its grievance policy after a family raised concerns about a resident with epilepsy, dementia, and cognitive communication deficit who required staff assistance for all ADLs. The family was not provided with documented follow-up or updates regarding their concerns about care, despite policy requirements for timely and ongoing communication.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent documentation, and unclear reporting mechanisms, resulting in inadequate protection for residents.
A resident with cognitive impairment and a care plan requiring staff assistance for grooming was observed with significant facial hair, despite CNA documentation indicating that shaving had been completed. The resident's care plan included a family request for the individual to be kept clean shaven, but direct observation revealed this was not done as required.
Two residents with cognitive impairment and on hospice care were physically assaulted by another resident with severe cognitive and psychiatric conditions, resulting in pain and swelling. Despite documented injuries and staff witness accounts, the facility did not substantiate abuse, citing lack of intent due to the aggressor's cognitive status.
A resident with multiple complex diagnoses was administered Lorazepam for anxiety without a documented anxiety diagnosis, targeted behaviors, or evidence of nonpharmacological interventions being attempted first. The care plan lacked person-centered behavioral interventions, and a behavioral health consultation was ordered but not completed, in violation of facility policy requiring proper assessment and alternative measures before psychotropic drug use.
A resident at an LTC facility experienced two falls, resulting in multiple femur fractures that were not reported to the hospital upon admission. The facility failed to fully investigate the falls, did not complete recommended follow-up radiographs, and did not ensure correct interventions were in place. Documentation was incomplete, and staff interviews revealed a lack of awareness and communication regarding the resident's condition and necessary follow-up actions.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the worsening of their conditions. One resident developed a stage IV ulcer with osteomyelitis due to inadequate repositioning and delayed medical oversight, while another developed an unstageable ulcer due to prolonged wheelchair use against physician orders. Documentation inconsistencies and untimely treatments were noted.
A resident experienced an 11.67% weight loss over six months, which the facility failed to identify and address in a timely manner. Observations showed the resident with an uneaten breakfast tray and no staff present. The facility did not update nutritional interventions since 2023, and the resident was not weighed weekly as required by policy. The new RD acknowledged the delay in addressing the weight loss.
The facility failed to maintain sanitary conditions in the kitchen, with raw chicken improperly thawed in a sink and several undated food items in the walk-in cooler. Dietary Staff M confirmed the chicken was thawed incorrectly and that food items should have been dated, violating the 2017 FDA Food Code.
A facility licensed for 126 residents failed to employ a full-time qualified social worker, leading to deficiencies in social services such as improper documentation of advance directives, unsafe discharge planning, and incomplete PASRR assessments. The facility had not employed a full-time social worker since March, with various individuals assisting part-time since a change in ownership in August. A new social worker was scheduled to start in September.
The facility failed to implement consistent infection control practices, affecting all residents. The Infection Control Nurse, who had multiple roles, did not provide required monthly reports or maintain accurate infection mapping. An LPN did not follow proper hand hygiene during trach care for a resident, as confirmed by the DON. These issues highlight significant lapses in the facility's infection prevention and control program.
The facility failed to prevent falls for a resident with dementia, provide appropriate care assistance for a resident with severe cognitive impairment, and ensure supervision to prevent altercations involving a resident with aggressive behaviors. Inconsistent documentation and lack of effective interventions contributed to these deficiencies.
The facility failed to provide adequate social services to eight residents, including coordination of advance directives, discharge planning, and completion of PASARR assessments. Two residents lacked social service assessments despite having significant medical needs. A change in ownership led to a gap in full-time social worker employment, contributing to these deficiencies.
The facility failed to implement an effective antibiotic stewardship program, affecting multiple residents. A review of infection logs revealed a lack of documentation on whether infections met criteria, with antibiotics prescribed without confirming appropriateness. The Infection Control Nurse acknowledged the issue, noting a new program would address it, but concerns remained.
The facility failed to ensure effective communication regarding advanced directives for two residents. One resident's medical record indicated a DNR status, but a nurse believed they were a full code, leading to potential miscommunication. Another resident expressed a desire to be a DNR, but the facility's records listed them as a full code. These discrepancies highlight the facility's failure to maintain accurate records of residents' advanced directives.
A resident with psychotic disorder and dementia was involved in an incident where they poured coffee on another resident, causing injuries. Despite the incident being documented and reported internally, the facility failed to report the allegation to the State Agency as required by their policy.
The facility failed to investigate allegations of abuse and injuries for two residents. One resident was involved in multiple altercations, including pouring coffee on another resident, but these incidents were not reported or investigated. Another resident was found with a bruised and swollen eye, but no investigation or reporting was conducted. The facility's policy requires immediate investigation of such incidents, which was not followed.
A resident admitted with epilepsy and dementia did not receive a required Level II PASARR screening after staying beyond the 30-day exemption period. The facility's Administrator, acting as the Social Worker, acknowledged the oversight, attributing it to a focus on guardianship issues following a recent change in ownership.
A resident who only speaks Arabic was not provided with adequate communication interventions, as the facility failed to utilize available resources such as an interpreter hotline and an Arabic flip guide. The care plan relied on an activities aide or family for translation, but on the day of observation, the aide was off duty, leaving staff unable to communicate effectively with the resident.
A facility failed to ensure a safe discharge for a resident with a tracheostomy and PEG tube, who was released without home health care or adequate nutrition. The DON stated that discharge planning usually involves the IDT, but the facility lacked a social worker to coordinate with outside agencies. No discharge progress note or home health care agency was ordered in the resident's medical record. The identified home health care agency confirmed the resident was not on their caseload due to insurance issues, which was communicated to the facility.
The facility failed to coordinate follow-up appointments for two residents, one with breathing issues and another with a tracheostomy and PEG tube, as per hospital discharge instructions. Additionally, there were errors in transcribing medication orders for a resident, leading to discrepancies and unnecessary contact isolation. These deficiencies highlight issues in care coordination and medication management.
A resident with hearing difficulties did not receive timely follow-up on audiology recommendations, including medical clearance for hearing aids and wax removal. Despite multiple physician notes and an audiology consult indicating moderate to severe hearing loss, the facility failed to act on these recommendations, leaving the resident without necessary hearing aids.
A resident with a diagnosis of shortness of breath was observed receiving oxygen at 5 liters per minute, contrary to the physician's order of 4 liters. An LPN documented the incorrect oxygen level without verification. The DON confirmed that nurses should verify oxygen levels before documentation.
A resident with severe cognitive impairment and multiple medical conditions developed a Stage 2 pressure ulcer that worsened to Stage 4 with osteomyelitis due to a lack of timely physician oversight. The facility failed to ensure medical evaluations were conducted from the ulcer's identification until a new wound physician was contracted, highlighting a significant deficiency in care.
A resident was not seen by a physician or physician extender at least once every 30 days for the first 90 days after admission, despite significant health changes and hospital admission. The resident developed a pressure ulcer and was diagnosed with acute osteomyelitis, aspiration pneumonia, and sepsis. The DON confirmed the lack of timely evaluations.
A facility failed to evaluate a CNA's competency, resulting in unsafe care for a resident with severe medical needs. The CNA provided care alone, contrary to the care plan requiring two-person assistance, and admitted to not consulting care plans or nurses. The facility lacked documentation of competency evaluations for the CNA.
The facility failed to properly manage controlled medications, leading to inaccurate documentation and potential diversion. An LPN was observed using a blank form for morphine, not accounting for unopened bottles, and inaccurately documenting Klonopin removal. The facility's policies lacked specific procedures for controlled substances, contributing to the deficiency.
The facility did not follow its medication storage policy, as observed when a refrigerator temperature checklist was outdated and applesauce was stored with medications. The DON confirmed the lapse, noting nightshift nurses were responsible for temperature checks. The policy requires medications to be stored separately from foods.
A resident with intact cognition and diagnoses of pain and dysphagia required dental extractions for fractured teeth. Despite recommendations from dental evaluations in February and April, the facility failed to make the necessary referral to an oral surgeon. The resident expressed ongoing pain and concern, and a July appointment was not completed due to the absence of a guardian. The facility administrator cited the lack of a social worker as a reason for the oversight.
A facility failed to coordinate and document a hospice care plan for a hospice respite patient. The DON admitted that communication with the hospice company was only verbal, with no formal documentation or log. The issue was acknowledged, but no further information was provided by the survey exit.
The facility failed to educate and offer the pneumococcal immunization to two residents, as required by its policy. The medical records for these residents lacked documentation of education or offering of the vaccine, and there was no indication of medical contraindications or prior immunization. The ICN overseeing vaccinations could not provide the necessary documentation, highlighting a lapse in policy adherence.
The facility failed to educate and offer the COVID-19 vaccine to two residents, as required by their policy. Medical records for both residents lacked documentation of education or vaccine offers, and there was no indication of medical contraindications or prior vaccinations. The ICN confirmed the absence of documentation and mentioned a new process for handling immunization education and consents.
The facility did not provide necessary Medicare/Medicaid notifications to residents, failing to issue Advance Beneficiary Notices (ABNs) to three residents and Notices of Medicare Non-coverage (NONMCs) to two residents. The facility was unable to locate the required documents during the survey.
A resident with a tracheostomy and severely impaired cognition was known to be noncompliant with their trach care, frequently removing the trach collar and cannula. Despite this, the facility failed to implement effective interventions to manage the resident's behavior. The resident was found unresponsive with the trach collar and tubing on the floor, leading to CPR and hospital transfer. Interviews revealed that staff were aware of the noncompliance, but no adequate interventions were documented or implemented.
The facility failed to maintain a separate accounting system for residents' trust funds, resulting in delayed credits and lack of financial statements for a resident. The resident's guardian reported ongoing issues and confusion about the account status, which was confirmed by facility records and staff interviews.
The facility failed to report an incident where a resident with vascular dementia and severely impaired cognition punched another resident, causing a small red circle under the eye. The incident was documented and reported internally but was not reported to the State Agency as required. The Administrator was unaware of the incident until questioned and found no evidence of an investigation or report to the SA.
Failure to Protect Resident From Physical Abuse and Address Psychosocial Impact After Resident‑to‑Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to address the abused resident’s subsequent psychosocial needs. On the evening of 1/10/26, one resident who ambulated without a device was walking in the hallway when another resident, who used a wheelchair, appeared to roll over the ambulatory resident’s foot. Witness statements from a CNA and an LPN indicated that the ambulatory resident then came around behind the wheelchair user near the elevator and punched the wheelchair user in the nose with a closed fist, causing immediate nasal bleeding, crying, and visible distress. The assaulted resident verbally stated that the other resident had hit her, and the aggressor resident was heard saying, “No, I meant to do it. These people are always touching me and rubbing on me. I'm tired of it.” The aggressor resident later told the NHA, DON, and surveyor that he had “knocked her in the face” or “punched her in the nose” after she ran over his foot or grabbed his pants, and acknowledged feeling angry and not liking to be touched. The assaulted resident had multiple diagnoses, including vascular dementia, generalized anxiety disorder, bipolar disorder, prior subarachnoid hemorrhage, muscle wasting, and malnutrition, and was severely cognitively impaired per a BIMS score of 6/15. Following the punch, she was emergently transferred to the hospital, where imaging confirmed bilateral nasal bone fractures. Progress notes and pain logs documented pain rated 10/10 requiring additional PRN acetaminophen, as well as visible anxiety and refusal of vital signs at the time of transfer. A subsequent physician note confirmed recent nasal fractures from being struck by another resident, described a small bruise on the bridge of the nose, and noted ongoing pain management with acetaminophen and morphine. The physician also documented that the resident was experiencing an acute psychotic episode with delusions and agitation in the context of recent trauma and hospitalization. The aggressor resident also had significant cognitive and psychiatric diagnoses, including dementia, schizophrenia, diabetic neuropathy, and an adjustment disorder with anxiety, and had a BIMS score of 6/15. Facility records showed a prior resident‑to‑resident assault by this same resident on another female resident months earlier, in which he struck her with a closed fist and police were contacted, with 15‑minute checks implemented for 48 hours. Despite this history and the facility’s abuse policy defining physical abuse as willful infliction of injury by non‑accidental means (including hitting and punching) and requiring immediate protection of residents and care plan revision when needs change as a result of abuse, the investigation documents indicated the facility did not verify that abuse occurred in the 1/10/26 incident. Additionally, review of the assaulted resident’s care plan showed no updates to address protection or psychosocial concerns after the event, even though the resident later reported feeling terrible about the incident, described ongoing head and ear pain, recounted bruising and attempts to cover it with makeup, and stated she did not feel safe in the facility and wanted to go home. A police report classified the event as a simple assault/battery, documented the aggressor’s admission that he punched the victim once in the face, and verified that a facility nurse witnessed the punch. The facility’s own abuse and neglect policy, updated 6/18/25, stated that abuse includes willful infliction of injury such as hitting and punching, and that any person, including other residents, may be a potential aggressor. The policy required immediate steps to assure resident protection and revision of the resident’s care plan if medical, nursing, physical, mental, or psychosocial needs changed as a result of an incident of abuse. In this case, the documented willful punch to the face by one resident against another, resulting in nasal fractures, severe pain, anxiety, and later expressed fear and lack of safety by the victim, along with the absence of care plan revisions to address the victim’s psychosocial needs, formed the basis of the deficiency for failure to protect the resident from abuse and to respond appropriately to the consequences of that abuse.
Failure to Ensure Consistent Availability of Linens and Laundry for Resident Hygiene and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring consistent availability of bath linens and adequate laundry services for multiple residents. An anonymous complaint alleged there were not enough linens to meet residents’ care needs. During interviews, several CNAs reported that linens, especially towels and washcloths, were short almost all the time, with some shifts starting with no linen available. CNAs described cutting bath blankets and using pillowcases to clean residents, and stated that shortages delayed resident care and showers. One CNA stated they did not understand the linen system and noted that laundry was typically done only in the morning, with no one staying to wash at night. Residents also reported not receiving necessary linens and hygiene items. One resident stated they did not get towels or washcloths and that staff had never offered them, relying instead on hygiene wipes brought by family and expressing a desire to use water for cleaning. Another resident reported that towels were short, they could not take showers as needed, and they had to “fight for a shower.” A resident described aides coming in and stating they were completely out of washcloths and towels and could not change the resident until they found some, resulting in the aides going on a “scavenger hunt” for linens. A family member reported that a resident had no laundry or clothes in the room, that a blanket brought from home had gone missing, and that most of the time the resident had no clothing available despite the family frequently refilling drawers. Observations of the clean utility linen supply closets on multiple units showed no washcloths and only a few towels, and no towels or washcloths were seen in residents’ rooms during interviews. The Housekeeping Supervisor reported that one laundry staff member had left and another had a broken arm, acknowledged that the laundry department was responsible for stocking clean utility rooms, and speculated that staff or residents might be keeping extra supplies in rooms. When the laundry room was toured, washers were running mainly with sheets, and there were no clean towels or washcloths in the clean laundry bins. A separate, closed construction unit—unavailable to floor staff—contained numerous unopened boxes of new towels and washcloths that were not in circulation; the Housekeeping Supervisor had no explanation for why these were not being used. The NHA later stated that this was considered emergency stock and that they believed staff had been delivering needed linens, although this was not supported by staff or resident reports or surveyor observations. Additional issues with residents’ personal clothing were identified. One resident, who was fully alert and oriented, reported frequently missing dresses and pants, and a room inspection with the NHA and Housekeeping Supervisor found only a few dresses and no pants. Another resident’s family member reported that the resident’s clothes and blanket repeatedly disappeared in laundry, that drawers were often empty of clothing, and that on the day of observation there were no clothes in the room except for a damp, urine-smelling shirt and pants that did not belong to the resident. The assigned CNA confirmed there were no clothes in the room and acknowledged ongoing shortages of washcloths, towels, and linens since starting work three months earlier, stating they had resorted to using wipes and draw sheets for care. The laundry aide reported linen shortages on the units, attributed mainly to being down two laundry staff, and stated that while supply was not the main problem, there was insufficient staff to get clothes and linens up to the floors. The facility had no written linen or laundry policy, and the only provided environmental services policy did not address laundering linens or residents’ clothing. Following the surveyor’s identification of concerns, later observations showed the clean utility rooms stocked with ample washcloths and towels, and no further shortages were reported during the remaining survey period. However, the deficiency centers on the period when residents and staff experienced ongoing shortages of towels, washcloths, and clothing, the lack of a defined linen/laundry policy, and the existence of substantial unused linen stock stored in an inaccessible construction area while residents lacked basic linens and adequate laundry support for personal hygiene and comfort.
Failure to Provide Adequate Supervision to Prevent Multiple Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one incident, a nurse heard a resident with severe cognitive impairment and a history of aggression yell at another resident to get out of his room, followed by observation of the second resident on the floor in the first resident’s room. The nurse then witnessed the first resident kick the second resident twice in the back/shoulder area while staff were attempting to assist the resident from the floor. Both residents had documented histories of aggression toward others, and both had psychiatric and cognitive diagnoses, including traumatic brain injury, dementia, schizoaffective disorder, bipolar disorder, schizophrenia, PTSD, and anxiety. The facility’s own investigation acknowledged that physical contact occurred between the two residents, resulting in a scratch on one resident’s neck, a cut on the other resident’s arm, and reported back pain. In a separate incident, two roommates were involved in a physical altercation after one resident was moved into the other’s room despite staff concerns. One resident, who was described by staff as aggressive and known not to like having roommates, was placed with another resident who was described as nice and who preferred the door open, in contrast to the aggressive resident’s preference for a closed door. Shortly after the room change, the second resident exited the room distressed and reported being hit by the roommate, initially stating they were hit in the face with a hand and also reporting being struck with a bathrobe related to a misunderstanding over clothing. The resident reported feeling unsafe in that room and only feeling safe after being moved, and staff confirmed that they had previously expressed concerns to administration that this roommate pairing would not be a good fit due to the aggressive behaviors of the first resident. Two additional incidents involved a resident with marked cognitive impairment who did not like others entering his room and another cognitively impaired resident who had a behavior of climbing into other residents’ beds, as well as a separate altercation between the same resident and another cognitively impaired resident in a hallway. In the first of these, staff responded to yelling and found one resident partially on the bed and the other resident in a wheelchair holding the first resident’s wrist and making physical contact. In the second, the resident who believed another resident had stolen his items confronted that resident in the hallway, and both residents struck each other in the face after the confrontation escalated. In all of these events, the residents involved had documented cognitive impairments and behavioral histories, and physical contact between residents was observed or confirmed by staff, demonstrating that supervision and monitoring were insufficient to prevent repeated resident-to-resident altercations. The facility’s staffing policy stated that adequate staffing would be maintained on each shift to ensure residents’ needs and services were met, including supervision and monitoring by licensed nurses and CNAs. Despite this, multiple resident-to-resident physical interactions occurred across different dates and units, involving residents with known behavioral issues and cognitive impairments. Staff interviews indicated that some concerns about roommate compatibility and aggressive behaviors were known prior to at least one of the incidents, yet the room assignment proceeded and an altercation followed. The pattern of events described in the report shows that the facility did not provide adequate supervision or environmental management to prevent these resident-to-resident altercations, resulting in physical contact, minor injuries, and distress for the residents involved.
Failure to Consistently Provide and Offer Required Evening Snacks
Penalty
Summary
The facility failed to ensure the consistent provision and availability of evening and bedtime snacks in accordance with residents’ needs and preferences. One resident, who was alert and oriented and restricted to bed, reported that they had never been provided or offered a snack by the facility and relied on family to bring snacks, expressing a desire to at least be offered something to see if there was an item they liked. Another alert and oriented resident in a wheelchair stated they were missing snacks at times, especially in the evenings, and explained that if they were not at the nurses’ station when snacks were passed out, they did not receive one. This resident described that snacks such as peanut butter and jelly sandwiches, pudding, and chips were available but that residents had to “run to that desk” to get them, and there were days they did not receive a snack despite wanting one daily. A family member of a nonverbal resident reported they were not aware of the resident receiving snacks and stated the resident seemed hungry during visits, leading the family member to request double food portions, which were often not received. During the interview, the nonverbal resident, who used a manual wheelchair, indicated through nonverbal cues (pointing to the surveyor’s and their own stomach and grimacing) that they were hungry at night, which the family member said occurred often. The family member had not been offered a grievance or concern form regarding snacks until prompted during the survey. The Dietary Manager reported that snacks such as chips, cookies, Jello, pudding, sandwiches, and rice crispy treats were prepared and sent to the unit on a tray, but acknowledged awareness of residents stealing and hoarding snacks and stated it was possible staff were taking snacks as they disappeared quickly. Although dry snacks were observed in the Dietary Manager’s office, residents’ reports and staff statements demonstrated that snacks were not reliably offered or made accessible to all residents as required by the facility’s policy, which states that all residents on regular diets are to be offered a bedtime snack each evening and that such snacks must be documented as offered.
Failure to Provide Timely ADL and Incontinence Care Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision of activities of daily living (ADL) care, including toileting and incontinence care, for multiple dependent residents. An anonymous complaint alleged short staffing, residents remaining in wet or soiled briefs for extended periods, and staff sleeping on the night shift, resulting in neglect of basic care needs. CNAs reported that when only two aides were scheduled instead of three on a floor of about 40 residents, they were unable to provide needed care, including timely feeding and two-hour check-and-change incontinence care, particularly on the midnight shift. Facility schedules showed multiple midnight shifts with only two aides assigned per floor despite a census in the 80s and 22 residents requiring lift assistance. Several residents described prolonged waits for assistance with toileting, incontinence care, and other basic needs. One bedbound, fully dependent resident reported that call lights often took up to two hours to be answered, that staff sometimes turned off the call light and said they would return but did not, and that some aides told them they went to the bathroom too often or were not “wet enough” to be changed despite the resident being on Lasix. This resident recounted an incident where a midnight aide performed inadequate perineal care, leaving stool that became hard and caked on by morning, which made the resident feel awful. Another bedbound, fully dependent resident reported waiting 1–2 hours after activating the call light to be changed, which caused frustration. Two alert, oriented residents who used manual wheelchairs reported frequently waiting about an hour or longer in bed for help with transfers, toileting, water, and medication, including an instance of waiting about an hour and a half for tray pickup and ice, and over an hour for an anxiolytic medication. Another resident’s family member reported repeatedly finding the resident “soaked” in urine during visits, including on the morning of the survey, and the resident nonverbally confirmed distress about being wet. These accounts, combined with staff interviews and staffing records, demonstrated that residents’ ADL and incontinence care needs were not being met in a timely manner, contrary to the facility’s written staffing policy stating that adequate staff would be maintained on each shift to meet residents’ needs and services.
Failure to Provide Consistent, Person-Centered Activities as Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent, meaningful, person-centered activities as scheduled and in accordance with residents’ preferences. One resident reported that the Activity Director posted monthly activity calendars but did not follow them, resulting in missed activities, particularly on weekends, such as BINGO and brain games. This resident stated that activity staff never conducted room visits, that music activities did not reflect their preferences, and that they were usually not taken on community outings when other residents went into the community. The resident described being bored on weekends and said they would attend activities if they were consistently offered. They also reported not being notified when activities were cancelled or times were changed, which caused frustration and upset. Surveyor observations corroborated these concerns. The activity calendar in the resident’s room showed a scheduled Brain Games activity on a Saturday, but the resident reported that when they went to attend, no one came to the activity room. The first-floor activity calendar posted in the dining room showed BINGO scheduled at a specific time, but when the surveyor observed the room during that period, there was no BINGO activity and no activity staff present. Another resident was observed waiting in their wheelchair in the dining room for BINGO to start and reported that activity staff were always late, that activities did not start on time, and that there were no activities on Sundays and some Saturdays. This resident stated that BINGO, previously held three times a week, was now only on Mondays and expressed frustration with the delays and missed activities. Further observations showed that the resident who had been waiting for BINGO left after waiting approximately 40 minutes, along with at least three other residents, and no activity staff or BINGO activity were present during that time. BINGO was later observed to have just started nearly an hour after the scheduled time. The Activity Director acknowledged that BINGO started late and attributed delays and missed activities to staffing shortages, a no call/no show by an activity aide, and the need to cover activities on both floors with limited staff. The Activity Director also acknowledged that activities were getting missed more often on the first floor, where residents were more independent, and that there were simultaneous activities scheduled on both floors that could not be covered by the available staff. Review of activity logs for the two residents showed participation on only a portion of days in the look-back period, similar dates with no activities documented, no refusals recorded, and minimal Sunday activities, despite a posted calendar indicating a full schedule. The facility’s policy stated that residents would be informed of activities through posted calendars, announcements, and individual communication, and that assistance would be provided to residents who wished to participate but could not get to activities on their own, but the documented and observed practices did not align with these procedures.
Failure to Protect Residents from Physical Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations that caused significant harm. One incident involved a resident with moderate cognitive impairment and a history of behavioral disturbances punching another resident in the face twice, breaking the victim's jaw. Witness statements and medical records confirmed that the altercation was witnessed by staff, and the injured resident reported severe facial pain and was subsequently transferred to the hospital for evaluation and treatment. The facility's documentation submitted to the State Agency did not accurately reflect the severity of the incident, as more detailed accounts in witness statements and the electronic medical record described greater injury and aggression than initially reported. Another incident involved the same resident who sustained the jaw fracture later pushing a third resident to the floor, then kicking and attempting to run over the resident with a wheelchair. Witness statements from nursing staff described observing the aggressor kicking the fallen resident and running into her with the wheelchair. The clinical record for the aggressor documented a history of combative and aggressive behaviors toward both residents and staff, including entering other residents' rooms, rummaging through belongings, and being verbally and physically aggressive. Despite this documented pattern, the facility's reporting to the State Agency again did not fully capture the extent of the altercation as described in internal records and staff statements. Interviews with staff revealed that some incidents of resident-to-resident aggression were not reported to facility leadership or the State Agency, and that staff had not received additional training on abuse reporting expectations. Staff also reported overhearing inappropriate comments from other staff members regarding the incidents, and there was acknowledgment of discrepancies between witness statements and the facility's official investigation documentation. The facility's abuse and neglect policy defined physical abuse and willful actions but did not appear to be consistently followed in practice, as evidenced by the incomplete and inaccurate reporting of serious resident-to-resident abuse events.
Failure to Timely Report and Accurately Document Suspected Abuse Incidents
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. In multiple incidents involving three residents, staff did not accurately or promptly report resident-to-resident physical altercations to the appropriate authorities. Documentation submitted to the State Agency did not fully represent the extent of the events as recorded in witness statements and the electronic medical record (EMR). For example, an incident where one resident struck another in the face was not reported to the Administrator until approximately seven hours after it occurred, and the initial report did not reflect the severity of the injury, which was later determined to be a fractured jaw. Further review revealed that staff, including a nurse who witnessed the incidents, did not consistently report all observed altercations. The nurse described witnessing additional aggressive interactions between residents, including physical assaults, but admitted to not reporting some of these events. The nurse also indicated a lack of training regarding the facility's abuse reporting protocols and expectations. There was no evidence that this nurse had received any abuse prevention or reporting education from the facility, despite the facility's claim of recent staff education efforts. Interviews with the Administrator and DON confirmed gaps in understanding and execution of reporting requirements. The Administrator delayed reporting an incident based on an initial assessment that there was no injury, only reporting after learning of a serious injury. The facility's own policy required immediate reporting of all allegations or suspicions of abuse to the Administrator and state agencies, but this was not followed. Additionally, the facility could not provide evidence that all staff, including agency nurses, had received the required training on abuse reporting procedures.
Insufficient Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on the second floor, as evidenced by multiple observations and interviews. On the day in question, only two CNAs were present for the first part of the shift due to a third CNA arriving late, and staff were unclear about their assignments. As a result, residents did not receive fresh water for two days, meal trays were delivered incorrectly or left in rooms for extended periods, and staff were unaware of which residents they were responsible for. Several residents, many with dementia or Alzheimer's disease, were observed without water within reach, with empty or outdated cups, or with no water available at all. Additionally, residents with a history of wandering were not redirected by staff, despite being observed entering and exiting multiple rooms that were not their own. Staff present in the hallway did not intervene or provide supervision. Interviews with CNAs and the RN assigned to the unit revealed that the workload was heavy, and tasks such as passing water and meal trays were delayed or not completed. The RN reported that medications were sometimes not given timely due to the workload, and agency CNAs were unfamiliar with their assignments and had not provided basic care such as water or meals to residents by mid-morning. The staffing coordinator and unit manager both confirmed that staffing was based solely on census rather than resident acuity, and that agency staff were used to fill gaps due to retention challenges. The facility's own policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved. The administrator and unit manager acknowledged that the lack of fresh water and delayed care should have been identified and addressed, but it was not recognized until brought to their attention during the survey.
Failure to Follow Grievance Policy and Provide Family Follow-Up
Penalty
Summary
Facility administration failed to adhere to its grievance policy regarding a resident with epilepsy, dementia, and cognitive communication deficit, who required staff assistance for all activities of daily living. The resident's family, who are also the legal guardians, submitted concerns about the frequency of changing and catheter monitoring. The facility's grievance documentation indicated that the family was not satisfied with the resolution and requested continued updates. However, there was no documented follow-up with the family after their concerns were verbalized. The facility's grievance policy requires the administrator or designee to contact the concerned party within 24 hours of receiving a grievance, provide written and oral explanations of findings within three to seven days, and maintain frequent contact until resolution. In this case, the administrator acknowledged that the follow-up was not completed, attributing the lapse to being off duty and leaving the responsibility to the DON, who was also unavailable. No further explanation or documentation of follow-up was provided by the end of the survey.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training, inconsistent documentation, and a lack of clear reporting mechanisms for suspected incidents. As a result, the facility was unable to demonstrate that it had taken adequate steps to protect residents from potential harm related to abuse, neglect, or theft.
Failure to Provide Grooming Assistance as Required by Care Plan
Penalty
Summary
A deficiency was identified when staff failed to provide necessary assistance with grooming for a resident who required help with activities of daily living (ADLs). The resident, who had diagnoses including epilepsy, dementia, and cognitive communication deficit, was assessed as having moderately impaired cognition and required staff assistance for all ADLs. The care plan specifically included an intervention, at the family's request, for the resident to be kept clean shaven. Despite this, the resident was observed with significant facial hair and in need of a shave during a surveyor's visit. Review of the medical record and CNA documentation showed that personal hygiene tasks, including shaving, were marked as completed multiple times on the days in question. However, direct observation contradicted these records, as the resident's facial grooming had not been performed according to the care plan. The unit manager confirmed that staff were expected to shave the resident during morning care, but no further explanation or documentation was provided regarding the discrepancy between the documentation and the resident's observed condition.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents where one resident physically assaulted two other residents. In the first incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses punched another resident in the face with a closed fist, resulting in swelling and pain near the lower jaw. The assaulted resident, who was receiving hospice care and had severe cognitive impairment, reported pain and swelling but was unable to provide a pain scale rating. In the second incident, the same resident exited his room while agitated and yelling, and punched another resident in the right cheek with a closed fist. This second victim was also on hospice care and had moderate cognitive impairment. Progress notes documented the physical assault and subsequent pain experienced by the resident. The aggressor was later placed on 1:1 supervision and transferred to a hospital following continued aggressive behavior. Despite clear documentation of physical contact and resulting pain and swelling, the facility concluded that abuse could not be substantiated, citing lack of intent due to the aggressor's poor cognition and the victims' inability to recall the incidents. The facility's policy defines abuse as causing physical harm, pain, or mental anguish, regardless of the perpetrator's mental or physical condition, and specifies that 'willful' refers to deliberate action, not necessarily intent to harm.
Failure to Implement Nonpharmacological Interventions and Behavioral Health Services Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions were implemented and utilized before administering pharmacological interventions for a resident with a history of traumatic brain injury, acute respiratory failure, acute embolism and thrombosis, and major depressive disorder. The care plan for fall risk included offering PRN anxiolytic medication for increased anxiety, despite the absence of an anxiety diagnosis for the resident. Documentation showed that Lorazepam was administered without evidence of targeted behaviors or moods warranting its use, and there was no record of consent for starting the medication. Additionally, there was no documentation of non-pharmacological interventions attempted prior to medication administration, nor was there a care plan for anxiety in place. A behavioral consultation was ordered but not completed, and the resident was not seen by behavioral health services as required. Facility policies require that psychoactive drugs only be used with a diagnosed specific condition and after alternative measures or consultation with appropriate health professionals. The facility did not follow these protocols, as evidenced by the lack of behavioral health service provision, absence of a person-centered behavioral care plan, and failure to document or attempt non-pharmacological interventions before administering a psychotropic medication.
Failure to Investigate Falls and Ensure Correct Interventions
Penalty
Summary
The facility failed to fully investigate two falls involving a resident, R804, and did not ensure that correct interventions were in place. R804 was transferred to the hospital emergency room due to low blood pressure, where it was discovered that the resident had multiple fractures in both femurs. The facility did not report these injuries to the hospital upon admission, and the incident was later addressed as an injury of unknown origin. R804's clinical record indicated a high risk of falls, with a Fall Risk Assessment score of 20. Despite this, the facility did not complete recommended follow-up radiographs after initial x-rays showed abnormal findings. The resident experienced two falls, one on 12/6/24 and another on 12/10/24, during transfers. The facility's documentation was incomplete, lacking interviews with involved CNAs and failing to identify all staff present during the incidents. Additionally, the care plan intervention to use a two-person assist for ambulation was not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition and the necessary follow-up actions. Nurse F was unaware of the need for additional x-rays, and the Director of Nursing did not believe the falls caused the fractures, despite the lack of thorough investigation. The facility's fall prevention policy was not effectively implemented, as evidenced by the inadequate tracking and intervention for R804's falls.
Plan Of Correction
1. Resident 804 no longer resides in the facility. 2. All residents that are categorized as “High Risk for Falls” based on their most recent fall assessment, or residents that have sustained a fall in the last 30 days, have the potential to be affected by the alleged deficient practice. By 3/7/2025, these identified residents will have their fall Care Plan reviewed by the Clinical IDT team to ensure appropriate fall interventions were in place and updated as needed. Any resident that has sustained a fall in the last 30 days will have their chart reviewed to ensure an IDT RCA along with a complete physical assessment of the resident has been completed and documented. 3. By 3/7/2025, the DON/designee will provide the following to all Clinical IDT members and licensed nurses: a. Fall Investigation Education with specific attention on determining and documenting the root cause of fall. b. Fall Prevention Education with specific attention on implementation of appropriate interventions. 4. The DON/designee will review 5 residents with sustained falls to ensure that a root cause analysis has been completed and documented, with immediate implementation of post-fall intervention along with a complete physical assessment of the resident. This review will occur 5 days per week for 4 weeks, then monthly thereafter for 3 months, or until substantial compliance has been maintained. Results will be presented monthly at the QAPI meeting for committee review. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 3/7/2025 and for sustained compliance thereafter.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, R58 and R22, and did not implement treatments in a timely manner or according to physician orders. Resident R58 developed a stage II pressure ulcer that progressed to a stage IV with acute osteomyelitis, while R22 developed an unstageable pressure ulcer. Observations revealed that R58 was consistently positioned on his back without appropriate off-loading devices, and there was a lack of timely medical provider oversight after the development of the pressure ulcer. R58 was admitted with severe cognitive impairment and was dependent on staff for mobility. Despite being at high risk for pressure ulcers, as indicated by a Braden Scale score, the facility did not adequately assess or document the progression of R58's wounds. There were inconsistencies in the documentation regarding the location and treatment of the pressure ulcers, and treatments were not administered as ordered. R58 was not evaluated by a medical provider after the development of the pressure ulcer until much later, contributing to the worsening of the condition. For R22, the facility failed to follow physician orders to keep the resident out of a wheelchair to prevent pressure ulcers. R22 was observed seated for extended periods, contrary to orders. The facility's documentation was inconsistent, with a pressure ulcer being identified as unstageable without prior documentation of its development. The facility's policy required weekly skin assessments and timely treatment, which were not adhered to, resulting in the development of an unstageable pressure ulcer.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to timely identify and address significant weight loss in a resident, referred to as R25, who experienced an 11.67% weight loss over six months. Observations revealed that R25 was found in bed with an uneaten breakfast tray and was not responsive to questions, although they continued to sip milk. The facility did not have staff present in the room at the time of observation. A review of R25's records showed a gradual weight loss from April to August 2024, which was not promptly identified or addressed by the facility staff. The care plans lacked updated nutritional interventions since 2023, and the facility's policy on nutrition monitoring was not followed, as R25 was not weighed weekly despite meeting the criteria for significant weight loss. The Registered Dietician (RD) C, who began working at the facility in August 2024, acknowledged the delay in identifying R25's weight loss and implementing interventions. RD C stated that they could not account for the actions of the previous dietician but took steps to address the issue once they became aware of it. The facility's policy required that any resident experiencing significant weight loss be evaluated by the Interdisciplinary Team and weighed weekly, but these measures were not in place for R25 at the time of the survey. No further explanation or documentation was provided by the facility by the end of the survey.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Raw chicken was found under running water directly inside the sink basin of a two-compartment sink, with an internal temperature of 67 degrees Fahrenheit. Dietary Staff M indicated that the chicken was initially in the walk-in cooler but was still frozen, leading to its placement in the sink for thawing. However, no explanation was provided for why the chicken remained in the sink at such a high temperature, which is inconsistent with the 2017 FDA Food Code requirements for thawing potentially hazardous food. Additionally, in the walk-in cooler, several food items were found undated, including pans of leftover enchiladas, white sauce, gravy, an opened package of bologna, and containers of Italian, ranch, and creamy Caesar dressings. Dietary Staff M confirmed that these items should have been dated upon opening. According to the 2017 FDA Food Code, ready-to-eat, potentially hazardous food held for more than 24 hours must be clearly marked with the date by which it should be consumed or discarded, which was not adhered to in this instance.
Failure to Employ Full-Time Social Worker Leads to Deficiencies
Penalty
Summary
The facility, licensed to care for 126 residents, failed to employ a full-time qualified social worker, resulting in multiple deficiencies in social services. These deficiencies included inadequate coordination of advance directives, leading to improper documentation of residents' desired code status in their clinical records. Additionally, there was a failure in discharge planning, which resulted in an unsafe discharge without necessary home health care services. The facility also did not complete Preadmission Screening and Resident Review (PASRR) assessments and failed to facilitate ancillary services such as dental and audiology, as well as assess residents for their social service needs. During an onsite annual recertification survey, it was revealed that the facility had a change in ownership on August 1, 2024, and had not employed a qualified social worker since the previous social worker's last day on March 28, 2024. The Human Resources Director and Corporate HR confirmed that various individuals were assisting with social services since the change in ownership, but none were onsite full-time. A new social worker was scheduled to start on September 4, 2024, but until then, the facility was without a full-time social worker, affecting the care of all 62 residents residing in the facility.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to consistently implement infection control standards and practices, affecting all 62 residents during the survey period. The Infection Control Nurse (ICN), who also served as the facility's Infection Preventionist, was responsible for the infection control program but was unable to provide monthly Infection Control Analysis reports for May, June, or July 2024, and there was no surveillance log for July 2024. The ICN, who had multiple roles including staff development coordinator and unit manager, devoted only four hours per shift to the infection control program and was unaware of the requirements for the analysis report. Additionally, the facility's infection mapping was inaccurate, as evidenced by discrepancies in the July 2024 antibiotic audit. A specific incident involving a resident with a tracheostomy tube and PEG tube highlighted further infection control deficiencies. During trach care, an LPN failed to perform hand hygiene between glove changes, moving from a dirty to a clean procedure, which was against the facility's infection control policy. The Director of Nursing confirmed that the LPN should have changed gloves and performed hand hygiene between cleaning secretions and applying clean gauze. This incident, along with the overall lack of effective infection control practices, demonstrates significant lapses in the facility's infection prevention and control program.
Deficiencies in Fall Prevention, Care Assistance, and Resident Supervision
Penalty
Summary
The facility failed to identify the root cause of multiple falls and implement effective interventions to prevent falls for a resident, resulting in multiple falls with injuries. The resident, who had dementia and severely impaired cognition, was observed in various positions and settings without consistent interventions to prevent falls. Despite being identified as a fall risk, the facility did not conduct thorough investigations or implement new interventions after each fall. The facility's documentation was inconsistent, with missing incident reports and follow-up assessments for several falls. Another deficiency involved the facility's failure to provide care according to a resident's assessed level of assistance. A resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and PEG tube, required assistance from two staff members for bed mobility. However, a CNA was observed providing care alone, contrary to the resident's care plan. The CNA reported not having access to care plans and deciding on the level of assistance independently, which was not in line with the facility's procedures. The facility also failed to ensure appropriate supervision to prevent resident-to-resident altercations. A resident with a history of aggressive behaviors and dementia was involved in multiple incidents of aggression towards other residents. Despite being identified as needing supervision, there were instances where the resident was left unsupervised, leading to altercations. The facility's lack of supervision and failure to implement effective interventions contributed to these incidents.
Deficiencies in Social Services Provision
Penalty
Summary
The facility failed to provide medically related social services to eight residents, as identified during an onsite annual recertification survey. The deficiencies included a lack of effective coordination of advance directives, resulting in improper documentation of residents' desired code status in their clinical records. Additionally, there was inadequate discharge planning, leading to an unsafe discharge without necessary home health care services. The facility also failed to complete PASARR assessments and did not facilitate necessary ancillary services such as dental and audiology, nor did they assess residents for their social service needs. For Resident #59, the medical record review revealed that despite being admitted with diagnoses of Bipolar disorder and Dementia, there were no completed social service assessments to identify any medical or psychosocial needs. The Director of Nursing confirmed the absence of such assessments. Similarly, Resident #60, who had diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction, expressed a desire to speak with a social worker for assistance with discharge planning and applying for Social Security. However, no social service assessments were completed for this resident either. The facility experienced a change in ownership, and since the previous social worker's resignation, there was no qualified social worker employed full-time. Various individuals were assisting with social services, but not on a full-time or onsite basis. This lack of consistent social service support contributed to the deficiencies observed during the survey, as the facility failed to meet the social service needs of its residents, impacting their overall quality of life.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain and implement an effective antibiotic stewardship program, affecting multiple residents who were prescribed and administered antibiotics. The deficiency was identified through a review of infection surveillance logs from April, May, and June 2024, which revealed a lack of documentation on whether infections met the criteria for an infection. For instance, a resident was prescribed Cephalexin for swelling and pain from an IV site, but the antibiotic was discontinued after a hospital admission revealed no infection. Another resident was readmitted from the hospital with pneumonia and started on Doxycycline, yet there was no documentation reviewing the appropriateness of the antibiotic. Further deficiencies were noted in June and July 2024. A resident was administered Levaquin for an unspecified infection without documentation of the infection type or criteria. Another resident was prescribed Amoxicillin-Pot Clavulanate for a UTI, but there was no documentation of symptoms meeting UTI criteria or the appropriateness of the antibiotic. In July, an audit revealed a resident on Macrobid for a UTI without a completed surveillance log or documentation of infection criteria. The Infection Control Nurse acknowledged the lack of documentation and stated that a new program would address these issues, but concerns about infection criteria and antibiotic appropriateness remained.
Failure to Honor Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure effective communication regarding advanced directives for two residents, R48 and R315. For R48, there was a discrepancy between the documented Do Not Resuscitate (DNR) order and the information available to the nursing staff. R48's medical record indicated a DNR status, signed by the resident's power of attorney and physician, yet Nurse D was under the impression that R48 was a full code, meaning they would perform full resuscitation if necessary. This inconsistency was noted during a conversation with the Administrator, who acknowledged the importance of aligning the profile page with the documented wishes to honor the resident's directives. For R315, there was a similar issue with the communication of code status. Although R315 expressed a desire to be a DNR and believed they had signed the necessary documents, the facility's records still listed them as a full code. The hospice nurse confirmed R315's DNR status, but the Director of Nursing (DON) was unaware of this and stated that the resident was a full code according to the hospice company. Upon further investigation, a signed DNR document for R315 was found in the hospice communication binder, indicating a lack of proper communication and documentation within the facility. These deficiencies highlight the facility's failure to maintain accurate and consistent records of residents' advanced directives, leading to potential miscommunication among staff and the risk of not honoring residents' end-of-life wishes. The discrepancies in the documentation and communication processes for both residents underscore the need for improved coordination and verification of advanced directives within the facility.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R11, to the State Agency. R11, who had diagnoses including psychotic disorder with delusions, anxiety, and dementia, was involved in an incident where they poured coffee on another resident, R37, and grabbed them, resulting in an abrasion to R37's cheek and discoloration to their lower right arm. Despite the incident being documented in the nurses' notes and reported to the family, unit nurse, administrator, and medical doctor, the facility did not report the allegation to the State Agency as required by their policy. The facility's policy mandates that all allegations of abuse be reported to the Administrator immediately and subsequently to the appropriate State Agencies. However, during a review of the facility's reported incidents in the State Agency's electronic system, it was found that the incident involving R11 and R37 was not reported. The Administrator confirmed the lack of reporting and documentation to the State Agency, acknowledging that the incident should have been reported and investigated according to the facility's abuse and neglect policy.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and injuries of unknown origin for two residents, R11 and R25. For R11, the medical record revealed multiple incidents where the resident was involved in altercations with other residents, including an incident where R11 poured coffee on another resident and grabbed them, resulting in injuries. Despite these incidents being documented in the progress notes, the facility did not report them to the State Agency or conduct any investigations. The new Administrator, who started in August 2024, confirmed that these incidents were not reported or investigated. For R25, the resident was found with a bruised and swollen left eye and a cut on the side of the left eye, which required medical attention. The incident was documented in the facility's incident report, but there was no evidence of an investigation or reporting to the State Agency. The current Administrator, who was not in the position at the time of the incident, was unable to provide hospital records or evidence of an investigation. The previous Administrator also did not recall being informed of the incident and stated that they would have initiated an investigation if they had known. The facility's policy on abuse and neglect requires immediate investigation of all allegations and incidents, but this was not followed in the cases of R11 and R25. The lack of investigation and reporting for these incidents represents a failure to comply with the facility's own policies and regulatory requirements, resulting in deficiencies in handling allegations of abuse and injuries of unknown origin.
Failure to Complete Level II PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a Level II PASARR screening was completed for a resident who remained in the facility beyond the 30-day exemption period. The resident, who was admitted with diagnoses including epilepsy and dementia, was initially given a hospital exemption discharge with a Level I screening indicating mental illness and recent use of antipsychotic or antidepressant medications. Despite the resident's extended stay, the facility did not submit a subsequent Level II screening as required. During an interview, the facility's Administrator, who was temporarily fulfilling the role of the Social Worker, acknowledged the oversight. The Administrator, recently hired following a change in facility ownership, admitted that their focus had been on addressing guardianship issues, which led to the neglect of the PASARR screening requirement. The Administrator confirmed that the resident should have undergone another screening after the initial 30-day period.
Failure to Implement Language Barrier Interventions
Penalty
Summary
The facility failed to implement adequate care plan interventions for a resident with a language barrier, specifically for a resident who only speaks Arabic. During an observation, the resident was seen in a wheelchair, and an attempt to interview them was unsuccessful due to the language barrier. A Certified Nursing Assistant (CNA) confirmed that the resident only speaks Arabic and stated that communication was typically facilitated through an activities aide who speaks Arabic or the resident's family. However, on the day of the observation, the activities aide was off duty, leaving the CNA without a means to communicate effectively with the resident. The resident's care plan, created on 8/30/23, included interventions such as providing a translator as needed, with the translator being the family or activities aide. However, the care plan did not include the use of an interpreter hotline, which the facility had available. The Administrator acknowledged the existence of the interpreter hotline but noted that it was not included in the care plan and that the CNA was unaware of it. Additionally, the facility had a flip guide in Arabic, which was also not utilized. This oversight led to a deficiency in the care provided to the resident, as the staff was not equipped with the necessary resources to communicate effectively with the resident.
Improper Discharge of Resident with Tracheostomy and PEG Tube
Penalty
Summary
The facility failed to facilitate a safe and coordinated discharge for a resident with a tracheostomy and PEG tube. The complaint alleged that the resident was improperly discharged into the community without home health care or adequate nutrition. During an interview, the Director of Nursing (DON) explained that discharge planning typically involves the interdisciplinary team (IDT) to discuss the resident's needs and necessary community resources. However, the facility lacked a social worker to effectively coordinate with outside agencies. It was noted that there was no discharge progress note or home health care agency ordered in the resident's medical record. The home health care agency identified by the DON confirmed that the resident was not on their caseload due to insurance coverage issues, which had been communicated to the facility.
Deficiencies in Follow-Up Care and Medication Transcription
Penalty
Summary
The facility failed to coordinate follow-up appointments for two residents, leading to a deficiency in providing appropriate treatment and care according to orders and residents' preferences and goals. One resident, who had been hospitalized for breathing issues, was supposed to have follow-up appointments with cardiology and pulmonology as per discharge instructions. However, the facility did not assist in making these appointments, and there was no documentation of a medical justification for not following through with the cardiologist and pulmonologist. The resident continued to experience shortness of breath and discomfort, indicating a lack of proper follow-up care. Another resident, who had a tracheostomy tube and PEG tube, was discharged from the hospital with instructions to follow up with a gastrointestinal specialist within 1 to 2 weeks. The facility failed to make this appointment, as confirmed by the Director of Nursing. This oversight in coordinating necessary follow-up care for residents with complex medical needs highlights a significant deficiency in the facility's care coordination processes. Additionally, the facility failed to properly transcribe hospital discharge orders for a resident, leading to medication discrepancies. The resident was placed in contact isolation based on hospital diagnoses, but upon review, it was found that the resident had completed their antibiotics and no longer required isolation. Furthermore, there were errors in transcribing medication orders from the hospital discharge paperwork, including incorrect indications for use and missing orders for prescribed medications. This lack of accurate transcription and verification of medication orders upon admission contributed to the deficiency in care provided to the resident.
Failure to Follow Up on Audiology Recommendations
Penalty
Summary
The facility failed to follow up on audiology recommendations and services for a resident who was hard of hearing. The resident, who was admitted in 2016 with diagnoses including major depressive disorder and Parkinson's disease, had a documented intact cognition with a BIMS score of 14. Despite multiple physician notes indicating the resident's hearing difficulties, there was no record of an audiology assessment or examination in the medical record. An audiology consult from February 2024 noted moderate to severe sensorineural hearing loss in both ears and recommended medical clearance for hearing aids and wax removal, but these recommendations were not followed up. The resident expressed difficulty in obtaining hearing aids and was not directed to the appropriate resources by the facility staff. The Administrator, who was also assisting with social work duties, was unaware of any audiology appointments for the resident until prompted by the surveyor. The Director of Nursing, recently hired, acknowledged the lack of follow-up and added the resident to the audiology list. However, no further documentation or explanation was provided before the end of the survey, indicating a deficiency in the facility's process for ensuring timely follow-up on audiology services.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident identified as R315. On the morning of August 27, 2024, an LPN was observed administering morning medications to R315 and documented the resident's oxygen saturation level as 97% on 4 liters of oxygen. However, upon inspection, the oxygen concentrator was found to be set at 5 liters. When questioned, the LPN acknowledged the error and adjusted the oxygen level to 4 liters, as per the physician's order. The LPN admitted to signing off on the oxygen level without verifying the actual administration level. The resident, R315, was admitted with a diagnosis of shortness of breath and had a physician's order for oxygen at 4 liters per minute via nasal cannula. There was no documentation in the medical record explaining why the oxygen level was increased to 5 liters. The Director of Nursing was informed of the incident and stated that nurses should verify the oxygen levels ordered by the physician before documenting them in the electronic record. The facility's policy on oxygen administration requires that oxygen therapy be administered as ordered by the physician or as an emergency measure until an order can be obtained.
Lack of Physician Oversight for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure physician oversight for a resident with pressure ulcers, leading to a significant deficiency. The resident, who had severe cognitive impairment and was dependent on staff for mobility and hygiene, developed a Stage 2 pressure ulcer that worsened to a Stage 4 with acute osteomyelitis. Despite the progression of the ulcer, there was no documented medical evaluation by a physician from the time the ulcer was first identified on July 4th until August 13th, when a newly contracted wound physician began seeing residents. This lack of timely medical evaluation contributed to the deterioration of the resident's condition. The resident was admitted with multiple complex medical conditions, including traumatic brain injury, respiratory failure, diabetes, and seizures. The facility's records indicated that the resident did not have any pressure ulcers upon admission. However, the facility's documentation and interviews revealed inconsistencies and delays in physician evaluations for pressure ulcers. The Director of Nursing acknowledged issues with timely physician visits, and the LPN responsible for wound care was uncertain about the evaluation process in the absence of a wound provider. This deficiency highlights a critical lapse in medical oversight and documentation for residents with pressure ulcers.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician or physician extender at least once every 30 days for the first 90 days after admission. The resident was initially seen by a physician for a competency evaluation and a History and Physical (H&P) shortly after admission. However, there was no documented evaluation by a medical provider after this initial visit, despite significant changes in the resident's condition, including a hospital admission and the development of a pressure ulcer. The resident experienced several health issues, including staring blankly, yellowish sputum, fever, and eventually required hospital transfer due to severe symptoms. The resident was diagnosed with acute osteomyelitis, aspiration pneumonia, and sepsis upon hospital admission. Additionally, the resident developed a pressure ulcer that worsened over time. The Director of Nursing confirmed the lack of timely physician evaluations and acknowledged the issue with physicians not seeing residents promptly.
Failure to Ensure CNA Competency Leads to Unsafe Resident Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was evaluated for the necessary skills and techniques to care for residents appropriately. This deficiency was observed when CNA 'H' provided care to a resident, R58, in an unsafe manner that did not align with the resident's assessed needs. R58, who had a tracheostomy tube and a PEG tube, was dependent on staff for all activities of daily living due to severely impaired cognition and other medical conditions, including diffuse traumatic brain injury and acute respiratory failure. Despite these needs, CNA 'H' performed tasks such as changing R58's brief and repositioning the resident alone, without the required assistance of a second staff member as indicated in the care plan. CNA 'H' admitted to not having access to care plans or instructions and relied on personal judgment for the level of assistance needed, stating that he did not consult with the nurse because he had been caring for the resident for a long time. A review of CNA 'H's personnel file revealed no competency evaluation or skills checklist to verify that he was evaluated before working with residents. The facility's administrator acknowledged the lack of completed competency evaluations and performance reviews, indicating a systemic issue in ensuring staff competency.
Deficiency in Controlled Medication Management
Penalty
Summary
The facility failed to establish and implement an effective system for managing controlled medications, which resulted in inaccurate documentation and potential medication diversion. During an observation, an LPN was seen preparing morning medications for a resident and was found to be using a blank controlled form for morphine medication. The LPN stated that unopened morphine bottles were not accounted for until opened, and the facility's staff only counted opened bottles, leading to discrepancies in the medication count. The facility's policy on controlled medications was reviewed and found lacking in specific procedures for receiving and accounting for controlled substances, contributing to the deficiency. Additionally, another incident involved an LPN inaccurately documenting the removal of a controlled substance, Klonopin, for a resident. The LPN recorded the removal of a pill on the count sheet two hours after it was supposedly administered, without actually removing a tablet at the time of documentation. The LPN admitted to not following the appropriate process for accounting for controlled substances, which should have been documented at the time of removal and administration. The DON confirmed that the facility's protocol required immediate documentation of any controlled substance removed from the supply.
Medication Storage Policy Violation
Penalty
Summary
The facility failed to adhere to its policy on the maintenance and storage of medications and foods in the medication storage room. During an observation, it was noted that the refrigerator temperature checklist had not been updated since 8/20/24, indicating a lapse in monitoring. Additionally, two applesauce containers were found stored alongside medications and insulins in the refrigerator. The Director of Nursing (DON) confirmed these findings and acknowledged that the nightshift nurses were responsible for checking the refrigerator temperature. The facility's policy clearly states that refrigerated medications should be kept in closed and labeled containers, separate from foods such as applesauce, and that other foods should not be stored in the medication refrigerator.
Failure to Ensure Dental Referral for Resident
Penalty
Summary
The facility failed to ensure a dental oral surgery referral was made for a resident who required extractions of fractured teeth. The resident, who was admitted with diagnoses including pain and dysphagia, had a BIMS score indicating intact cognition. A dental evaluation in February recommended referral to an oral surgeon for surgical extractions of teeth #2 and #19 due to discomfort from fractured teeth. A subsequent evaluation in April reiterated the need for extraction of tooth #19, which was non-restorable and causing pain. Despite these recommendations, the necessary referral was not made. The resident expressed ongoing pain and concern about the lack of assistance from the facility in addressing their dental needs. A progress note from July indicated that the resident was unable to be seen by a dentist without a guardian present, and the appointment needed to be rescheduled. The facility administrator acknowledged the lack of a social worker to make the referrals and mentioned that a new social worker had been recently hired. This oversight resulted in the resident continuing to experience dental pain without the required surgical intervention.
Lack of Coordinated Hospice Care Plan
Penalty
Summary
The facility failed to ensure a coordinated and documented plan of care for hospice services for a resident identified as R315, who was a hospice respite patient. During an observation, R315 was found lying in bed with a family member present and mentioned being at the facility for a short period. An interview with the Director of Nursing (DON) revealed that communication with the hospice company was conducted verbally, without any formal documentation or log. The DON acknowledged the communication issue and mentioned informing the administrator about the need to communicate requirements and expectations to the hospice company. No additional information was provided by the exit of the survey.
Failure to Educate and Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to provide education and offer the pneumococcal immunization to two residents, identified as R26 and R58, out of five residents reviewed for the pneumococcal immunization. For R26, there was no documentation in the medical record indicating that the resident or their representative had been educated about or offered the pneumococcal immunization. Additionally, there was no documentation showing that the immunization was medically contraindicated or that the resident had already been immunized. R26 was admitted to the facility on an unspecified date. Similarly, for R58, the medical record lacked documentation of education and offering of the pneumococcal immunization to the resident or their representative. There was also no documentation indicating a medical contraindication or prior immunization. R58 was admitted to the facility on an unspecified date and had a readmission on another unspecified date. The facility's policy, dated 8/1/24, states that all residents should be offered the pneumococcal vaccine upon admission, unless contraindicated or already vaccinated, and should receive education about the vaccine's benefits and potential side effects. The Infection Control Nurse (ICN) overseeing the vaccinations was unable to provide the necessary documentation for these residents, indicating a lapse in the facility's adherence to its own policy.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine and/or booster to two residents, identified as R26 and R58, as part of their COVID-19 vaccination policy. Upon review of R26's medical record, there was no documentation indicating that the resident or their representative had been educated about or offered the COVID-19 vaccine. Additionally, there was no record of the vaccine being medically contraindicated or that the resident had already received the vaccine or booster. R26 was admitted to the facility on an unspecified date. Similarly, R58's medical record lacked documentation of education and an offer of the COVID-19 vaccine to the resident or their representative. There was also no indication of medical contraindication or prior vaccination. R58 was admitted and later readmitted to the facility on unspecified dates. The facility's policy, dated 9/23/23, mandates that all residents be offered COVID-19 vaccines unless contraindicated or already vaccinated, with prior education on benefits and side effects. The Infection Control Nurse (ICN) overseeing vaccinations confirmed the absence of documentation for both residents and mentioned a new process under new ownership to bundle education and consents for all immunizations.
Failure to Provide Required Medicare/Medicaid Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to residents, as required. Specifically, the facility did not issue an Advance Beneficiary Notice (ABN) to three residents and failed to provide a Notice of Medicare Non-coverage (NONMC) to two residents. During the survey, a Skilled Nursing Facility (SNF) Beneficiary Notification Review form was completed by the State Agency representative and given to the facility for completion and return. However, the facility administrator was unable to locate any of the requested ABNs and NONMCs for the residents in question by the time of the survey exit.
Failure to Implement Effective Tracheostomy Care and Supervision
Penalty
Summary
The facility failed to provide effective tracheostomy care and supervision for a resident with a tracheostomy, leading to a critical incident. The resident, who had diagnoses including respiratory failure, dysphagia, tracheostomy status, and autistic disorder, was documented to have severely impaired cognition and required assistance for all activities of daily living. The resident was known to be noncompliant with their tracheostomy, frequently removing the trach collar and cannula. Despite this, the facility did not implement adequate interventions to address the resident's noncompliance. On the day of the incident, the resident was found unresponsive on the floor with the trach collar and tubing on the floor, and only the inner cannula in place. CPR was initiated, and the resident was transferred to a hospital. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed awareness of the resident's noncompliance with their tracheostomy. However, no effective interventions were documented or implemented to manage the resident's behavior. The Director of Nursing acknowledged that continuous monitoring should have been added to the resident's care plan but was not. The lack of appropriate interventions and monitoring contributed to the resident's critical condition and subsequent transfer to the hospital.
Failure to Maintain Resident Trust Fund Accounting
Penalty
Summary
The facility failed to establish and maintain a system that assures complete and separate accounting for residents' trust funds from the facility's operating account. This deficiency was identified through a complaint received by the State Agency, which revealed that a resident's guardian had repeatedly requested financial statements and account audits since December 2023 but received no satisfactory response. The facility's business manager was fired, and the role was left unfilled for a period, leading to further delays and confusion. The resident's guardian reported ongoing issues with the trust fund, including being informed that the account was overdrawn despite having funds available, and not receiving any trust fund account statements for over a year. The facility's records confirmed that the monthly patient allowances were not credited timely to the resident's trust fund account, with a lump sum credit being made only in April 2024, just before the account was closed at the guardian's request. Interviews with the facility's business office manager in training and the regional business office manager revealed that the facility had a process for mailing out quarterly account statements, but the last statement was mailed in April for the period of January through March. The regional business office manager admitted that the facility had to move the credit from their operating account to the trust fund account, which was not done timely. The facility administrator confirmed that they had spoken with the resident's guardian multiple times but did not document these grievances. The administrator also acknowledged that the business office manager no longer worked at the facility and that the regional business office manager was assisting the guardian. The facility's policy on resident trust funds required accurate accounting and safe handling of resident funds, including timely crediting of funds and regular review of accounts. However, the facility failed to adhere to these policies, resulting in the resident's guardian being uninformed about the resident's personal funds and the potential for misuse of those funds. The facility's failure to provide timely financial statements and maintain a separate accounting system for the resident's trust funds led to significant confusion and concern for the resident's guardian.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse to the State Agency (SA) within the required timeframe. The incident involved a resident with vascular dementia, anxiety disorder, and heart disease, who had severely impaired cognition. The resident was observed to have physically aggressive behavior towards other residents. On the day of the incident, a CNA reported that the resident punched another resident unprovoked, resulting in a small red circle under the other resident's left eye. Despite the incident being documented in nursing notes and reported to the doctor, Director of Nursing (DON), and Power of Attorney (POA), it was not reported to the SA as required by state and federal regulations. The Administrator, who served as the Abuse Coordinator, was unaware of the incident until questioned by the surveyor. Upon review, the Administrator found no evidence that the incident had been reported to the SA or that an investigation had been conducted. The Administrator explained that she had been on sick leave at the time, and the DON, who was the backup Abuse Coordinator, no longer worked at the facility. The Administrator also did not know the identity of the resident who was punched, as the LPN and Social Work Director (SWD) involved in the incident also no longer worked at the facility.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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