Kalispell Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalispell, Montana.
- Location
- 171 Heritage Way, Kalispell, Montana 59901
- CMS Provider Number
- 275025
- Inspections on file
- 27
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Kalispell Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with severe dementia and a history of falls was not provided with adequate supervision or individualized interventions to address her wandering and behavioral risks. Despite multiple injuries, including a compression fracture and a fractured hip, the care plan lacked specific strategies for fall prevention and behavioral management. Staff interviews and documentation revealed inconsistent monitoring, insufficient staffing, and a lack of effective interventions, resulting in repeated accidents and injuries.
A resident with severe dementia and a history of wandering and aggression was not provided with adequate supervision or individualized interventions, resulting in repeated incidents of entering other residents' rooms, altercations, falls, and injuries. Care plans were not tailored to the resident's needs, pain management was inconsistent, and required monitoring was not properly documented, leading to distress and harm for both the resident and others.
Residents repeatedly reported issues with inadequate housekeeping and missing laundry items over several months, with concerns documented in Resident Council meetings and confirmed by staff interviews. Despite these ongoing complaints, the facility did not resolve the problems, resulting in continued deficiencies in cleaning and laundry services.
The facility failed to provide a clean and homelike environment and did not properly manage residents' laundry, resulting in persistent cleanliness issues and frequent loss or misplacement of personal clothing. These failures led to repeated resident complaints and an altercation between two residents over misidentified clothing, with staff confirming ongoing problems in both housekeeping and laundry processes.
The facility did not report allegations and findings of abuse within the required timeframes for a resident involved in a physical abuse incident with staff and for two residents involved in a verbal altercation. Delays were attributed to technical issues and failure of staff to promptly report incidents, resulting in late notifications to the State Survey Agency.
A resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and elopement risk did not have a care plan with specific, person-centered interventions. The care plan relied on vague redirection strategies and lacked individualized pain management, fall prevention, and activity planning. Staff were unaware of the full extent of the resident's behaviors, and meaningful activities were not provided for residents in the memory care unit, resulting in inconsistent and unsafe care and unmet psychosocial needs.
The facility did not provide daily, individualized or group activities for residents with dementia in the secure memory care unit. Observations and interviews with family and staff confirmed a lack of meaningful engagement, with residents often left sitting in silence without activities. Requested documentation of activity participation was not provided, and facility policies requiring special consideration for dementia care were not followed.
A resident with dementia and a diagnosis of wandering was not accurately assessed for daily wandering behaviors on the MDS, as staff did not review all relevant medical diagnoses or interview family members. This led to incomplete documentation and care planning that did not address the resident's actual wandering frequency.
The facility failed to respond to residents' call lights in a timely manner, resulting in inadequate pain management and feelings of insecurity. Residents reported waiting over 30 minutes for assistance, particularly at night, due to understaffing. Staff confirmed insufficient staffing, leading to delays in addressing residents' needs. One resident with multiple health conditions experienced daily pain and inadequate repositioning assistance. The facility's call light audit goal of a 5-minute response time was not met, contributing to resident dissatisfaction.
The facility failed to implement proper infection control measures, including adherence to transmission-based precautions and documentation of COVID-19 testing. Staff entered rooms without PPE, and there was confusion about which residents required contact precautions. Additionally, COVID-19 testing for close contacts was not documented, and the facility lacked a system for monitoring waterborne illnesses.
The facility failed to maintain a clean environment in resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations showed unclean shower rooms with used washcloths and pooled dirt, while interviews revealed frequent reports of missing clothing and personal items. The facility's grievance process and inventory management were ineffective, with insufficient staff training contributing to the deficiencies.
The facility failed to maintain an effective grievance program, particularly regarding lost resident belongings. Staff interviews revealed inconsistencies in elevating issues to a formal grievance level, and a missing grievance log was noted. A resident discharged with missing items, including an iPad and Apple Watch, had unresolved grievances despite these items being inventoried.
The facility failed to manage pain effectively for several residents, including one with advanced dementia who showed signs of distress without receiving scheduled pain medication. Another resident experienced delays in receiving pain relief, affecting mobility and increasing the risk of skin breakdown. Additionally, a resident reported unmanaged pain with missed assessments, and another was unfamiliar with the pain scale, indicating systemic issues in pain management.
The facility failed to follow up on dental care referrals for several residents, resulting in unresolved dental issues and ill-fitting dentures. A resident had multiple dental concerns identified by a hygienist, but no follow-up was documented. Other residents experienced difficulties eating due to poorly fitting dentures, with one resident experiencing significant weight loss. No documentation of dental appointments was provided.
The facility's dietary department failed to serve meals on time, resulting in cold food for residents. Breakfast and lunch were consistently delayed, with residents reporting dissatisfaction with the food quality. Some residents received meals that did not match their dietary needs, and staff members confirmed the poor quality of the food.
The facility failed to provide adequate supervision in the memory care unit, leading to resident confrontations and unsafe conditions. A resident eloped due to ineffective wanderguard systems, and two residents were improperly positioned during meals, increasing choking risks. Staff shortages and non-compliance with care plans contributed to these deficiencies.
A facility failed to refer a resident for a PASARR Level II assessment after a PTSD diagnosis was added. The resident, with a history of military service and being a prisoner of war, had a PASARR Level I assessment that did not include PTSD. A staff member acknowledged the need for a new Level I assessment, but no Level II request was made before the survey ended.
A facility failed to document a resident's need for enteral tube feeding in their baseline care plan, despite the resident's history of spinal cord injury, Parkinson's, and aspiration pneumonia, and being NPO. The admitting nurse did not include this critical information, and the floor nurse did not complete the care plan, contrary to facility policy.
The facility failed to provide necessary assistance to two residents with activities of daily living (ADLs). One resident, dependent on staff for eating, was observed struggling to feed himself without assistance. Another resident with Parkinson's disease was found struggling to dress herself after using the bathroom, despite needing supervision and assistance as per her care plan.
The facility failed to ensure timely hospice referrals for two residents, resulting in significant delays in care. One resident experienced a delay in hospice referral despite a fall and a request from their POA, while another resident faced confusion over palliative care orders, leading to unmanaged pain and immobility concerns. Staffing issues and lack of a palliative care policy contributed to these deficiencies.
A facility failed to provide necessary treatment for a resident diagnosed with PTSD. The resident, a veteran with a history of combat and imprisonment, expressed the need for psychiatric or counseling services. Despite the diagnosis, no referral for treatment was made, and staff confirmed the lack of action. No documentation was provided to show any referral for PTSD treatment.
The facility did not follow the posted menus for two out of three observed meals, serving different items than those listed. This included missing whole grain toast at breakfast and serving an entirely different lunch menu, potentially affecting residents relying on the posted menus for their nutritional needs.
The facility failed to adhere to physician-ordered therapeutic diets for three residents. A resident on a CCHO diet reported high blood sugar levels due to inappropriate meal content, while another had to remind staff to provide sugar-free syrup. A resident with end-stage renal disease was not provided a renal diet, and staff were unaware of specific dietary needs. Budget constraints and lack of awareness contributed to these deficiencies.
A resident did not receive two prescribed medications, Cefdinir and Potassium Chloride, during an evening medication pass, resulting in a 6.4% medication error rate. Staff interviews confirmed that the absence of documentation in the MAR indicated a medication error. The facility's policy requires timely administration and documentation of medications, which was not followed in this instance.
A significant medication error occurred when a staff member in an LTC facility pre-poured medications and mistakenly gave a resident high-dose opioids instead of Tylenol. The staff member failed to follow the facility's medication administration procedures and did not monitor the resident's health adequately after the error. The resident was found unresponsive and required hospital treatment for an opioid overdose.
A LTC facility failed to prevent significant medication errors for two residents, leading to an Immediate Jeopardy situation. A resident was mistakenly given high doses of opioids instead of Tylenol, resulting in an opioid overdose and hospitalization. Another resident received an incorrect dosage of Trospium due to a transcription error, although no adverse effects were reported. The facility's medication administration and error monitoring policies were not adequately followed, contributing to these errors.
A resident was given incorrect medications, leading to an opioid overdose and hospitalization. The facility also failed to assess two residents' ability to consent to sexual contact, resulting in an incident in the memory care unit. Additionally, a resident-to-resident abuse event occurred when a wandering resident was pushed, causing a fall.
The facility failed to protect two residents from falls and hazards, resulting in multiple injuries. One resident experienced eight falls in 17 days, with significant injuries, while another was pushed by a fellow resident due to wandering. Staff were unaware of care plan updates, and interventions were not effectively communicated or enforced, leading to inadequate supervision and safety measures.
A facility failed to report a medication error leading to a resident's medical neglect and an incident of inappropriate sexual contact between two residents. The medication error involved incorrect administration of Vicodin and OxyContin, resulting in the resident becoming unresponsive and requiring Narcan. Additionally, two residents were found in a potentially nonconsensual sexual situation, but their capacity to consent was not assessed, and the incident was not reported to the State Survey Agency.
A facility failed to investigate a significant medication error where a resident was given incorrect medications, leading to unconsciousness and hypoxia. The investigation lacked input from key personnel and did not include education for other nurses. Additionally, the facility did not assess the capacity to consent in a sexual contact incident between two residents, leading to ongoing inappropriate behaviors affecting another resident. The facility's policy on abuse prevention was not followed, as no assessments were conducted prior to the incident.
The facility failed to maintain a clean environment, affecting twelve residents. Observations revealed unclean rooms with dried food, dust, and feces on toilet seats. Residents reported infrequent housekeeping, with some rooms cleaned only once a week. Staff interviews confirmed understaffing in housekeeping, and grievance reports showed ongoing concerns about cleanliness and supply refills.
The facility failed to provide a structured activities program for residents in the memory care unit, as observed and reported by staff and a resident. Interviews revealed inconsistencies in activity provision, with some staff noting limited engagement in activities like coloring and television, while others confirmed the absence of structured activities and an activities aide since November 2023.
A staff member failed to prime an insulin pen before administering insulin to a resident, contrary to the facility's policy. The staff member, on her first day at the facility, was unaware of the priming process. The facility's policy requires a 2-unit dose of insulin to be released as an air shot before each use.
A resident admitted for rehabilitation experienced inadequate care, including long wait times for assistance, lack of help with repositioning and toileting, and poor hygiene management. The resident was discharged with open sores and feeling mistreated, highlighting a failure in meeting care needs despite having a care plan in place.
A staff member failed to perform proper hand hygiene and use protective measures during medical procedures for a resident. She did not sanitize her hands or don gloves during blood glucose monitoring, insulin administration, or the administration of eye drops. Additionally, she placed the glucometer on the resident's table without a barrier and failed to clean it after use, contrary to facility policy.
The facility failed to ensure a clean environment for 10 of 14 sampled residents, leading to feelings of discouragement and frustration. Observations revealed soiled diapers, dirty floors, and food wrappers. Staff interviews indicated housekeeping was short-staffed, resulting in uncleaned rooms. One resident's room had crumbs, debris, a soiled bed pad, and a broken sink handle, with complaints unaddressed.
A facility failed to implement care planned fall interventions for a resident at risk for falls. The resident was found on the floor without footwear, in a dimly lit room, and without non-slip strips or a fall mat. Staff interviews revealed various reasons for the failure, including the removal of the fall mat and a delay in applying non-slip strips.
A resident with a history of falls and severely impaired cognition experienced multiple falls due to the facility's failure to implement fall prevention interventions. The resident was found on the floor in a dimly lit room with wet urine and no non-skid strips or fall mat. Staff inconsistencies and lack of communication contributed to the failure to follow the resident's care plan.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with a significant history of falls and cognitive impairment. The resident, who resided in the memory care unit and had severe dementia, was known to wander frequently and had altercations with other residents. Despite being identified as a high fall risk with previous injuries, the care plan did not include sufficient or specific interventions to address her safety needs, wandering behavior, or fall prevention. The care plan goals were unrealistic given her cognitive status, and interventions lacked detail regarding her pain management, mobility limitations, and behavioral triggers. Multiple incidents were documented where the resident sustained injuries, including a compression fracture and a fractured hip requiring surgery. These injuries resulted from both witnessed and unwitnessed falls, as well as altercations with other residents. Progress notes and staff interviews revealed that supervision was inconsistent, and staff were often unaware of the resident's whereabouts. There was a lack of documentation regarding the direct causes of falls, the effectiveness of interventions, and whether appropriate supervision was in place at the time of each incident. Staff reported being too busy to provide adequate oversight, and 1:1 observation, when implemented, was not maintained as a long-term intervention. The facility's policies required systematic monitoring and management of residents at risk for elopement or unsafe wandering, but these were not effectively implemented for this resident. The care plan did not address specific needs such as toileting schedules, safe wandering paths, or individualized behavioral interventions. Staff interviews confirmed that interventions were limited to redirection, and additional measures such as visual cues or environmental modifications were not consistently used. The lack of adequate supervision and failure to implement effective, individualized interventions directly contributed to the resident's repeated falls and injuries.
Failure to Provide Adequate Supervision and Individualized Dementia Care
Penalty
Summary
A resident with severe dementia, poor safety awareness, and a history of aggressive behaviors and wandering was admitted to the memory care unit. The resident exhibited continuous wandering, entered other residents' rooms, displayed aggression, and had multiple falls, some resulting in significant injuries such as a hip fracture and a compression fracture. Despite being identified as high risk for elopement and falls, the resident was not consistently provided with individualized interventions or adequate supervision to address her specific behavioral and safety needs. Documentation showed that staff were often unaware of her whereabouts, and interventions such as 1:1 observation were implemented only temporarily and not maintained, even though staff reported these measures were effective in ensuring safety. The care plans developed for the resident were not sufficiently individualized or tailored to her needs. Goals set for the resident, such as developing coping skills for cognitive decline, were unrealistic given her severe cognitive impairment. Interventions lacked specificity, and there was no clear plan for managing her pain, which may have contributed to her behaviors. The care plan also failed to identify patterns in her wandering or provide detailed strategies to prevent her from entering other residents' rooms. Staff interviews revealed a lack of consistent use of visual cues or other non-pharmacological interventions, and staff expressed concerns about insufficient staffing and supervision. Additionally, the facility failed to consistently administer pain medications as ordered, which was noted by the provider as a concern and may have contributed to the resident's ongoing agitation and behavioral issues. Monitoring tools, such as 15-minute checks, were not completed as required, and documentation was often incomplete or inaccurate. The lack of adequate supervision and oversight resulted in repeated incidents where the resident intruded into other residents' rooms, leading to altercations and injuries, and caused distress and fear among other residents. The facility's actions and inactions did not meet the resident's behavioral, safety, and cognitive needs as required.
Failure to Address Resident Concerns with Housekeeping and Laundry Services
Penalty
Summary
The facility failed to address ongoing concerns raised by residents regarding housekeeping and laundry services, as documented in Resident Council minutes over several months. Residents repeatedly reported issues such as inadequate cleaning of their rooms, particularly toilets and floors, and missing laundry items that were not returned for extended periods. Despite these concerns being brought up consistently from September through December, the problems persisted without resolution. Observations and interviews confirmed that laundry items were often unlabeled, inventory records were incomplete or not updated, and mesh bags intended to help track laundry were not consistently used by nursing staff. Staff interviews further revealed that complaints about insufficient cleaning and missing laundry were common and had been discussed both in Resident Council meetings and through individual grievances. Specific areas, such as the B hall, were noted as not being cleaned frequently, and residents expressed dissatisfaction with the thoroughness of housekeeping. The facility's failure to respond effectively to these repeated concerns resulted in ongoing deficiencies in both laundry and housekeeping services, affecting any resident whose needs in these areas were not met.
Failure to Maintain Clean Environment and Proper Laundry Management
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents, as evidenced by persistent cleanliness issues and mismanagement of residents' personal laundry. Observations over several days revealed multiple dried spills, dirt, debris, and bug traps with accumulated dust and insects throughout various hallways and resident rooms. Specific rooms and common areas were noted to have unclean floors, uncollected trash, and visible stains, despite cleaning logs indicating recent cleaning. Residents and staff reported ongoing complaints about inadequate housekeeping, with grievances and Resident Council minutes documenting repeated concerns about insufficient cleaning, especially in resident rooms, bathrooms, and dining areas. Laundry management was also deficient, with staff interviews and observations indicating that residents' clothing was frequently unlabeled, leading to confusion and loss of personal items. Laundry staff described a process where unmarked clothing was hung on racks in hallways, as they were unable to identify the owners. Missing item forms and grievance forms were often completed when residents reported lost clothing, but inventories were not consistently updated when new items were brought in. This resulted in a significant accumulation of unclaimed clothing and limited storage space. Staff also noted that families sometimes resisted labeling clothing, further complicating the process. These deficiencies culminated in an altercation between two residents when one resident recognized his clothing being worn by another. The clothing in question had been relabeled with the second resident's name after the original label was crossed out. Facility records showed multiple grievances related to missing clothing and laundry delays, as well as complaints about room and facility cleanliness. Staff interviews confirmed that these issues were ongoing and had been raised repeatedly by residents and staff alike.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations and findings of abuse in a timely manner to the State Survey Agency for three sampled residents. In one instance, an alleged incident of physical abuse involving two staff members and a resident occurred, but the event was not reported within the required two-hour timeframe, and the final findings were not submitted within the required five working days. Staff attributed the delay to technical issues with the abuse reporting system. In another case, a verbal altercation between two residents was not reported until two days after the event, as it was only discovered during a chart review. The nurse involved did not report the incident immediately, resulting in late notification. The facility's policy requires immediate reporting of abuse allegations, but these procedures were not followed in the cited incidents.
Failure to Develop Person-Centered Care Plan and Provide Individualized Dementia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and was at risk for elopement. The care plan lacked specific dementia-related interventions and relied primarily on nonspecific redirection strategies. Staff interviews revealed that key team members were unaware of the full extent of the resident's behaviors, such as constant wandering, and therefore did not include appropriate interventions in the care plan. The care plan did not provide measurable or detailed actions for staff to follow, and interventions were often generic or unrealistic given the resident's cognitive status. Record reviews showed that the care plan did not address the resident's pain management needs, as interventions for pain in the right knee were missing, and pain goals were not individualized or specific to the resident's condition. The plan for cognitive decline included unrealistic goals, such as developing coping skills, despite severe cognitive impairment. Interventions for falls, elopement, and aggressive behaviors were vague, lacked specificity, and did not reflect the resident's actual patterns or needs. For example, the falls care plan did not address the resident's weakness, confusion, or poor safety awareness, and did not specify which items should be kept within reach or how to anticipate the resident's needs. Additionally, the facility failed to provide meaningful activities for residents in the memory care unit, as reported by both family and staff interviews. The care plan for elopement risk referenced offering preferred activities, but none were listed, and interventions were generic and not tailored to the resident. The lack of individualized, person-centered interventions and activities resulted in staff lacking clear guidance to effectively meet the resident's needs, leading to inconsistent and potentially unsafe care, as well as unmet psychosocial needs for multiple residents.
Failure to Provide Individualized Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of daily, individualized or group activities and meaningful engagement for residents with dementia residing on the secure memory care unit. Observations revealed that several residents were sitting in the common room without any music, television, or interactive activities occurring. Multiple interviews with family members and staff confirmed that there were no consistent activities provided for residents in the secure unit, with staff noting a lack of time and resources to conduct such activities. Family members reported never witnessing activities during their visits, and staff expressed concern about the absence of daily engagement, which they identified as important for redirecting and ensuring the safety of dementia residents. Documentation regarding activity participation for three sampled residents in the secure memory care unit was requested but not provided by the facility. Review of facility policies indicated that special considerations should be made for developing meaningful activities for residents with dementia and that appropriate treatment and services should be provided to meet their highest practicable well-being. Despite these policies, the facility did not demonstrate that activities were planned or implemented for residents in the secure memory care unit, leading to a deficiency in meeting their cognitive and psychosocial needs.
Failure to Accurately Assess and Document Resident Wandering Behaviors
Penalty
Summary
The facility failed to accurately identify and document wandering behaviors on the MDS Resident Assessments for one resident with dementia and a known history of daily wandering. Staff responsible for completing the admission MDS assessment did not review the resident's medical diagnoses or fully consider behaviors prior to admission, instead assuming the assessment only pertained to current behaviors observed within the facility. The staff member also did not interview the resident or family members, relying solely on progress notes, which resulted in the omission of the resident's daily wandering behavior from the assessment. The resident's electronic health record indicated a diagnosis of wandering at admission and contained multiple progress notes documenting daily incidents of wandering and exit-seeking from the day of admission onward. Despite this, the admission MDS assessment indicated no wandering behaviors, and the subsequent quarterly MDS assessment understated the frequency of wandering. This inaccurate documentation limited the facility's ability to implement appropriate care plan interventions to address the resident's actual care needs.
Inadequate Staffing Leads to Delayed Call Light Response and Pain Management
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, leading to inadequate pain management and feelings of insecurity among residents. Multiple residents reported waiting over 30 minutes for their call lights to be answered, particularly during night shifts. One resident mentioned waiting over an hour for assistance, while another expressed concerns about the facility being understaffed, especially at night, with only two CNAs available for over 60 residents. Staff interviews corroborated these concerns, with reports of insufficient staffing due to budget constraints, leading to delays in addressing residents' needs. Additionally, residents experienced delays in receiving pain medication, with one resident waiting over an hour for Tylenol to manage hip pain. Another resident, with a history of spondylosis, arthropathic psoriasis, and other conditions, reported daily pain and inadequate repositioning assistance. Staff members acknowledged the staffing issues, noting that nurses were often overburdened with responsibilities, including administering medications and conducting assessments, without adequate support. The facility's call light audit indicated a goal of a 5-minute response time, which was not being met, contributing to resident dissatisfaction.
Infection Control and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper implementation of transmission-based precautions, documentation, and notification of COVID-19 tracing, and lacked a system to prevent and monitor waterborne illnesses. Observations revealed that staff members did not adhere to contact precautions, as they entered rooms of residents under such precautions without wearing personal protective equipment (PPE). Specifically, staff members were seen in a resident's room without PPE despite the resident being on contact precautions for shingles. Additionally, there was confusion among staff regarding which residents required contact precautions, leading to incorrect signage on room doors. The facility also failed to document COVID-19 testing for residents who were close contacts of a staff member who tested positive. Although testing was conducted, progress notes for several residents did not reflect the testing or results. Furthermore, a resident who was a close contact was placed on oxygen due to low saturation levels, but staff were unaware of the resident's status in the COVID-19 testing protocol. Lastly, the facility lacked procedures or systems to address waterborne microorganisms, as confirmed by a staff member, despite having a policy that required such measures.
Deficiencies in Cleanliness and Personal Item Management
Penalty
Summary
The facility failed to maintain a clean and safe environment in the resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations revealed that the shower rooms, particularly outside the memory care unit, were not properly cleaned, with used washcloths, pooled dirt, and malodorous smells present. Additionally, there were brown stains near the drain and a dirty brief on the floor, indicating a lack of proper sanitation and infection control measures. The facility also failed to exercise reasonable care in managing residents' clothing and personal items, leading to frequent reports of missing belongings. Several residents and staff members reported missing clothes and personal items, such as an iPad and an Apple Watch, which were not adequately addressed through the facility's grievance process. The facility's system for tracking and returning lost items was ineffective, with staff spending significant time searching for missing items and a lack of a clear policy or procedure for handling such issues. Interviews with staff revealed that the facility's inventory process for residents' personal belongings was insufficient, with only a small portion of the staff having received training on completing inventory listings. The facility's failure to provide a comprehensive and effective system for managing residents' personal items and maintaining a clean environment contributed to the deficiencies identified during the survey.
Deficient Grievance Program for Lost Resident Belongings
Penalty
Summary
The facility failed to maintain an effective grievance program to address resident concerns, particularly regarding lost belongings. Observations and interviews revealed that grievances related to missing items were not consistently elevated to a formal grievance level by management. Staff member C, identified as the grievance officer, indicated that the administrator and director of nursing were responsible for determining which issues were considered grievances. Staff member A noted that the grievance log for August 2024 was missing and acknowledged that not all concerns were documented as grievances, sometimes resulting in incomplete records. Resident #67, who had recently been discharged, was still missing personal items, including an iPad, an Apple Watch, and clothing, which were documented in the resident's personal belonging inventory. Despite these items being inventoried, a grievance was not resolved for the lost belongings. The report highlights that grievances were not being addressed effectively, as evidenced by the grievance report forms dated 3/1/24, which expressed dissatisfaction with the grievance process. This deficiency increased the risk of negative outcomes for residents with unresolved grievances or lost items.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to ensure proper pain management for several residents, leading to deficiencies in care. Resident #14, who has advanced dementia, was observed to be in distress and exhibiting behaviors indicative of pain, such as grimacing and rocking. Despite these signs, the resident's medication administration reports showed no scheduled pain medication, only PRN orders, and there were numerous missed opportunities for pain assessments. The resident's care plan and progress notes indicated behaviors consistent with pain, yet there was a lack of consistent pain management interventions. Resident #29 reported frequent pain in her left hip and experienced delays in receiving pain medication, affecting her ability to move and increasing the risk of skin breakdown. Despite a physician's order for palliative care, the facility did not have such services, and staff were unclear about the order's implementation. This lack of clarity and delay in pain management contributed to the resident's discomfort and potential health risks. Resident #10 also reported unmanaged pain and a lack of regular pain assessments, with several missed assessments documented in the electronic health record. The resident's diagnoses included conditions that could cause significant pain, yet the facility failed to document pain progress notes when pain levels were reported at 5/10 or higher. Similarly, resident #30 was unfamiliar with the pain scale and had several missed pain assessments, with most assessments inaccurately recorded as 0/10. The facility's failure to provide a pain management policy further highlights the systemic issues in addressing residents' pain needs.
Failure to Follow Up on Dental Care Referrals
Penalty
Summary
The facility failed to follow up on dental care referrals for several residents, leading to unresolved dental issues. Resident #5 had been seen by a dental hygienist who identified multiple dental concerns, including possible decay, broken teeth, and root tips. Despite a physician's order for a dental referral dated April 15, 2024, there was no evidence of follow-up or treatment for these issues in the resident's electronic health record (EHR) as of January 13, 2025. Staff member B acknowledged the referral was received in May 2024 but was not acted upon. Additionally, residents #48, #3, #6, and #280 experienced issues with ill-fitting dentures, impacting their ability to eat properly. Resident #48 reported difficulty eating certain foods due to poorly fitting dentures and experienced a significant weight loss of 6.15% over two months. Residents #3 and #6 also reported problems with their dentures slipping or not fitting, leading to difficulties in eating. Resident #280 was observed leaving food on his plate due to his dentures not fitting well, which he stated affected his ability to consume enough protein for his renal diet. No documentation of dental notes or appointments for these residents was provided by the end of the survey.
Delayed and Unappetizing Meals Served to Residents
Penalty
Summary
The facility's dietary department and staff failed to serve meals in a timely manner, resulting in cold food being served to residents. Observations and interviews revealed that breakfast was consistently served late, with some residents reporting delays of up to an hour. For instance, a resident in the dining room noted that breakfast was typically 30 minutes late, while another resident in the E wing reported receiving cold eggs when her tray was delivered. Additionally, lunch was also served late, as evidenced by a resident in the A wing who frequently received cold meals. Furthermore, several residents expressed dissatisfaction with the quality of the food. One resident relied on family members to bring in meals due to disliking the facility's food. Another resident found her oatmeal too thick and was not provided with the lactose-free milk indicated on her meal ticket. Additionally, a resident was observed picking out burnt pieces from her eggs, expressing displeasure with the food quality. Staff members corroborated these complaints, with one describing the food as "disgusting" and another stating that residents compared it to "jail food."
Inadequate Supervision and Positioning in LTC Facility
Penalty
Summary
The facility failed to provide adequate staff supervision on the memory care unit, affecting three residents. Staff members reported that the unit had a high number of residents with behavioral issues, yet staffing levels were insufficient, with only three staff in the mornings and two in the afternoons. This lack of supervision was evident when a surveyor had to intervene in a confrontation between two residents, as no staff were present to manage the situation. Additionally, a resident was observed walking barefoot with an unstable gait and holding a fork, posing a risk of injury, while staff were occupied elsewhere. The facility also failed to implement effective interventions for a resident who eloped. Staff expressed concerns about the inefficiency of the wanderguard system, noting that some doors did not lock when a wanderguard was near, allowing the resident to exit the facility. The transitional care unit, where the resident resided, was unsupervised and had multiple exit points, further contributing to the elopement risk. Furthermore, the facility did not ensure proper positioning for two residents during meals, increasing the risk of choking. One resident was observed coughing and struggling to swallow while slouched in a chair, contrary to dietary orders requiring an upright position. Another resident was left in a flat position with a kinked neck while eating, which staff acknowledged could be a choking hazard. These observations highlight the facility's failure to adhere to care plans and dietary orders, compromising resident safety during meals.
Failure to Refer Resident for PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident for a PASARR Level II assessment after a diagnosis of Post Traumatic Stress Disorder (PTSD) was added. The resident, who had a history of serving in the special forces during the Korean and Vietnam wars and was a prisoner of war, had a PASARR Level I assessment dated 6/21/24 that did not include the PTSD diagnosis. The resident's Minimum Data Set (MDS) dated 6/27/24 also did not reflect the PTSD diagnosis, but a subsequent MDS dated 9/22/24 did include it. During an interview, a staff member acknowledged that a new PASARR Level I should have been completed when the PTSD diagnosis was added to determine if a Level II assessment was necessary. However, no Level II request was made before the survey concluded.
Failure to Document Enteral Feeding in Baseline Care Plan
Penalty
Summary
The facility failed to include critical information on a resident's baseline care plan regarding their need for enteral tube feedings. This oversight was identified for one of the sampled residents who had a history of spinal cord injury, Parkinson's disease, and aspiration pneumonia, and was designated as NPO (nothing by mouth) due to the risk of aspiration. Despite the resident's medical history and specific provider orders for continuous tube feeding with Isosource 1.5 at 70 ml/hr and free water flushes, the baseline care plan did not reflect these essential care requirements. During an interview, a staff member indicated that the admitting nurse is responsible for initiating the baseline care plan for new admissions, and if incomplete, the floor nurse should finalize it. However, the care plan for this resident failed to document the need for enteral feeding, which was acknowledged as a necessary inclusion by the staff. The facility's policy mandates a comprehensive, person-centered care plan to address each resident's needs, but this was not adhered to in this instance, increasing the risk of improper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance to a resident during meals. Observations revealed that a staff member was the only one available to pass medications and food trays, which led to a situation where a resident, who was marked as dependent on their MDS for eating, was left attempting to feed himself without assistance. On multiple occasions, the resident was observed struggling to eat and drink without staff assistance or cueing, despite the care plan indicating the need for extensive assistance by one staff member. Another deficiency was noted in the facility's failure to assist a resident with toileting and dressing. The resident, who has Parkinson's disease, expressed that her ability to use the bathroom fluctuates and that she needed assistance. Despite this, she was found struggling to dress herself after using the bathroom, visibly upset and crying, with her call light on. The care plan indicated that she required supervision for toileting and setup assistance for dressing, but these needs were not met, as evidenced by the resident's struggle and the lack of staff assistance.
Delayed Hospice Referrals and Care Plan Confusion
Penalty
Summary
The facility failed to ensure timely hospice referrals for two residents, leading to significant delays in care. For one resident, an order for a hospice referral was received due to weight loss and senile degeneration of the brain, but the referral was not completed until eleven days later. This delay was compounded by a significant fall that resulted in an emergency room visit. Despite the resident's power of attorney expressing a desire to start hospice, the process was delayed by a month. Staff interviews revealed that the facility struggled with managing lab results, new orders, and referrals due to staffing issues, and hospice admissions were reportedly delayed by two weeks. Another resident experienced severe pain post-CVA and had a physician's order for hospice referral, but there was confusion regarding the implementation of palliative care. The resident reported significant pain and delays in receiving pain medication, and there was concern about skin breakdown due to immobility. Despite a physician's order for palliative care, staff indicated that the facility did not have a palliative care policy, leading to further confusion and inaction. The lack of communication and clarity regarding the resident's care plan contributed to ongoing pain management issues.
Failure to Provide PTSD Treatment for Veteran Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, a veteran who experienced combat in Korea and Vietnam and was a prisoner of war, expressed the need for psychiatric or counseling services for PTSD. Despite having a medical diagnosis of PTSD, the resident had not been referred for appropriate treatment. Staff confirmed that no referral had been made, and no documentation was provided to show that a referral for PTSD treatment had been initiated by the facility.
Failure to Follow Posted Menus
Penalty
Summary
The facility failed to adhere to the posted menu for two out of three observed meals, which could potentially affect any resident relying on the posted menu. During observations on January 14, 2025, at 8:33 a.m., 8:37 a.m., and 8:41 a.m., whole grain toast was not present on a resident's plate, despite being listed on the breakfast menu for that day. Additionally, on January 15, 2025, at 12:37 p.m., the lunch served included potato soup, ham and cheese on a croissant, watermelon, and a cupcake, which did not match the posted lunch menu that listed garden vegetable soup, classic beef stroganoff, lemon buttered broccoli, a baked roll, and raspberry jello salad. These discrepancies indicate a failure to follow the planned and posted menus, which are intended to meet the nutritional needs of the residents.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that physician-ordered therapeutic diets were followed for three residents. Resident #12, who was on a consistent carbohydrate (CCHO) diet, reported that the meals provided were not suitable for her diabetic condition, as they contained too many carbohydrates. She mentioned that her blood sugar levels were often high since her admission, and she had to bring her own food. Resident #48, also on a CCHO diet, had to remind staff to provide sugar-free syrup, as they would often serve regular syrup with her breakfast. Staff member F confirmed that therapeutic diets, particularly for dialysis and diabetic residents, were not being followed due to budget constraints. Resident #280, who had end-stage renal disease and required a renal diet, expressed difficulty in consuming enough protein due to ill-fitting dentures, which made it hard to chew meats. Despite his condition, his electronic health record indicated a regular diet with soft and bite-sized textures, rather than a renal diet. Staff member J noted that diabetic residents were receiving the same diet as others without dietary restrictions, and there were no sugar-free snack options available. Staff member L was unaware of the renal diet and misunderstood the requirements of a carbohydrate diet. The facility's document on therapeutic diets stated that snacks should be compatible with the therapeutic diet, which was not being adhered to in practice.
Medication Administration Error
Penalty
Summary
Facility nursing staff failed to administer two medications during the evening medication administration time for a resident, resulting in a 6.4 percent medication error rate. The medications involved were Cefdinir, an antibiotic prescribed to be taken twice daily for pneumonia, and Potassium Chloride, prescribed twice daily for encephalopathy. The resident's electronic health record (EHR) showed physician orders for these medications, but the medication administration record (MAR) did not document them as given during the scheduled medication pass. Interviews with staff members confirmed that if a medication is not marked off in the MAR as given, it is considered a medication error. The facility's policy on administering medications, revised in December 2012, requires that medications be administered safely, timely, and as prescribed, with documentation in the MAR after each administration. The failure to document the administration of these medications as per the policy led to the identified deficiency.
Significant Medication Error Due to Non-compliance with Medication Administration Procedures
Penalty
Summary
The facility experienced a significant medication error involving a resident who was given incorrect medications by a staff member. The staff member, while administering medications, pre-poured medications for two residents to save time, which is against the facility's policy. During this process, the staff member mistakenly gave a resident a 10 mg Vicodin and 60 mg OxyContin, both high-dose opioids, instead of the requested Tylenol. This error occurred because the staff member did not adhere to the facility's medication administration procedures, which require verifying the resident's identity and checking the medication label three times. Following the medication error, the staff member failed to implement appropriate health monitoring for the resident. The staff member did not take baseline vital signs, did not monitor the resident's oxygen saturation continuously, and did not look up the side effects of the medications administered. Approximately two hours after the error, the resident was found unresponsive with low blood pressure and low oxygen saturation. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the hospital. The resident's medical records showed a lack of documentation of vital signs or consciousness state between the time of the medication error and the hospital transfer. The hospital records indicated that the resident was treated for an opioid overdose and developed aspiration pneumonia. The facility's policies clearly outlined the procedures for medication administration and monitoring after a medication error, which were not followed by the staff member involved.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in an Immediate Jeopardy level deficiency for one resident. A staff member mistakenly administered a high dose of opioid medications, Vicodin and OxyContin, to a resident who requested Tylenol. The staff member pre-poured medications for efficiency, which led to the error. After realizing the mistake, the staff member contacted the on-call provider but did not take immediate vital signs or monitor the resident's oxygen saturation. The resident was later found unresponsive with low blood pressure and oxygen saturation, requiring emergency medical intervention and hospitalization for an opioid overdose. Another resident received an incorrect dosage of Trospium due to a transcription error in the electronic medical record. The order was entered incorrectly as 60 mg four times a day instead of the intended 60 mg once daily. This error went unnoticed for several days until the pharmacy identified the mistake. The resident received double the recommended dose for a week, although no adverse effects were reported. The facility's policies on medication administration and error monitoring were not followed, contributing to these errors. The staff failed to verify the resident's identity and medication details adequately, and the double-check system for entering medication orders was not effectively implemented. These lapses in protocol led to significant medication errors, posing serious risks to the residents' health and safety.
Medication Error and Inadequate Resident Protection
Penalty
Summary
The facility failed to protect a resident from neglect of medical care when a licensed staff member administered incorrect medications, resulting in a significant medication error. The staff member gave the resident 10 mg of Vicodin and 60 mg of OxyContin, which were not prescribed for the resident. Following the error, the staff member did not take baseline vital signs or place the resident on continuous oxygen saturation monitoring. Approximately two hours later, the resident was found hypotensive, with low oxygen saturation levels, and unresponsive. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the emergency room, where they were treated for an opioid overdose and aspiration pneumonia. The facility also failed to protect two residents in the memory care unit from engaging in sexual contact without prior assessment of their ability to consent. Staff members found the two residents naked in bed together, but there was no documentation of an assessment to determine their capacity to consent to sexual activity. Both residents had cognitive impairments, with one having a diagnosis of unspecified dementia and the other having a diagnosis of Frontotemporal Neurocognitive Disorder and unspecified dementia. The facility's policy required an evaluation of the residents' capacity to consent, which was not conducted. Additionally, the facility failed to protect a resident from a resident-to-resident abuse event that resulted in a fall. A resident with a history of wandering entered another resident's room, leading to a confrontation where the second resident pushed the first, causing them to fall. The facility's policy on abuse prevention was not adequately enforced, as the staff was aware of the wandering behavior but did not prevent the incident. The resident who fell had diagnoses of repeated falls, muscle weakness, altered mental status, Alzheimer's disease, and dementia.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to protect two residents from accidents and hazards, leading to multiple falls and injuries. Resident #9 experienced eight falls within 17 days, resulting in significant injuries, including a traumatic subarachnoid hemorrhage and compression fractures. Despite being identified as a high fall risk, interventions were not effectively implemented or communicated among staff. Staff member F admitted to not knowing how to access or update care plans, and there was a lack of staff signatures on a document outlining interventions for Resident #9. Resident #10, who has a history of wandering due to Alzheimer's and dementia, was pushed by another resident, resulting in a fall. The incident occurred in a memory care unit where residents frequently wander into each other's rooms. Staff member K acknowledged the difficulty in preventing such incidents, and staff member F used Google Translate to communicate with Resident #10, who only speaks Russian. The care plan for Resident #10 included wearing appropriate footwear and redirecting her from other residents' rooms, but these measures were not effectively enforced. The facility's documentation and communication regarding fall risks and interventions were inadequate. Staff members were not fully aware of care plan updates, and incidents were not consistently logged. Resident #9's falls were not included in the fall log because she had been discharged, indicating a lack of comprehensive tracking and follow-up on fall incidents. These deficiencies highlight a failure in ensuring a safe environment and adequate supervision for residents at risk of falls.
Failure to Report Neglect and Inappropriate Sexual Contact
Penalty
Summary
The facility failed to identify and report an incident of suspected medical neglect involving a resident who was given the wrong medications by a staff member. The staff member administered 10 mg of Vicodin and 60 mg of OxyContin by mistake, and although the provider was notified, the resident was not placed on a continuous oxygen saturation monitor nor were vital signs taken immediately. The resident was found unresponsive three hours later, requiring Narcan and emergency medical intervention. The facility's administrator and another staff member did not recognize the incident as neglect and failed to report it to the State Survey Agency. Additionally, the facility did not report an incident of inappropriate sexual contact between two residents to the State Survey Agency. One staff member found the residents naked in bed together but did not assess their capacity to consent to sexual behavior, assuming the interaction was consensual. Both residents had diagnoses that could impair their ability to consent, including unspecified dementia and Frontotemporal Neurocognitive Disorder, yet their electronic medical records lacked assessments of their ability to consent and documentation of the incident. The facility's policy on abuse prevention outlines the need to report incidents of neglect and nonconsensual sexual contact, but these incidents were not reported as required. The State Survey Agency's reporting system showed no record of the incidents being reported, indicating a failure in the facility's adherence to its own policies and regulatory requirements.
Failure to Investigate Medication Error and Assess Consent in Sexual Contact
Penalty
Summary
The facility failed to fully investigate a significant medication error involving a resident who was given incorrect medications, resulting in the resident becoming unconscious and hypoxic. A staff member accidentally administered 10 mg Vicodin and 60 mg OxyContin to a resident who did not have these medications prescribed. The staff member administered Narcan and called 911, but there was a lack of documented vital signs monitoring between the time of the error and the resident's transfer to the hospital. The investigation into the incident was inadequate, lacking input from the QAPI committee, medical director, and consultant pharmacist. Additionally, there was no evidence of education or policy review for other nurses following the incident. The facility also failed to investigate an incident involving sexual contact between two residents who were not assessed for their capacity to consent. A staff member found two residents naked in bed together, but no assessment was conducted to determine if the contact was consensual. Another resident reported inappropriate sexual comments from one of the involved residents, leading to her isolation in her room. The facility did not provide documentation of any investigation or capacity assessments prior to the incident, and assessments were only completed after the surveyor's request. The facility's policy on abuse prevention requires an evaluation of a resident's capacity to consent to sexual activity if there is any suspicion of incapacity. However, this policy was not followed, as no assessments were conducted before the incident. The lack of investigation and assessment allowed ongoing inappropriate behaviors to go unaddressed, affecting the well-being of other residents.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations and interviews conducted during a survey. Twelve out of fourteen sampled residents had rooms that were not cleaned regularly, with issues such as dried food particles, dust, and sticky substances on the floors, as well as dried feces and urine on toilet seats. Residents reported that housekeeping services were infrequent, with some rooms being cleaned only once a week or less. The lack of cleanliness extended to common areas, with hallways also noted to have sticky substances and dirt. Interviews with staff revealed that the facility was understaffed in housekeeping, with only one housekeeper present at times and no replacements available when staff called off. The housekeeping supervisor acknowledged the complaints and stated that the best service would involve daily cleaning of residents' rooms. The facility's grievance reports indicated ongoing concerns about housekeeping, with issues such as garbage not being emptied, floors not being swept, and supplies not being refilled. These grievances had been consistently raised by the resident council and individual residents over several months.
Lack of Structured Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide a structured activities program tailored to meet the individual preferences and needs of residents in the secured memory care unit. This deficiency was identified through observations and interviews conducted on June 4, 2024. A resident from the general care unit noted that residents from the memory care unit did not participate in activities outside their unit. Staff interviews revealed inconsistencies in the provision of activities, with some staff members stating that certified nursing assistants (CNAs) engaged residents in activities like coloring, puzzles, and television programming, while others indicated a lack of structured activities and the absence of an activities aide. Observations in the memory care unit showed residents sitting in recliners and at tables with the television on, but no structured activities were taking place. Staff members confirmed the absence of an activities aide since November 2023 and acknowledged the lack of structured activities in the unit. The deficiency was attributed to the absence of a dedicated activities aide and the reliance on CNAs to provide activities, which were not consistently implemented or structured to meet the residents' needs.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Staff member M failed to provide services that met professional standards of quality by not priming an insulin pen before administering insulin to a resident. During an observation, staff member M was seen retrieving two new insulin pens for the resident and labeling them with an opening date. However, staff member M did not prime either the Tresiba or Novolog insulin pen with 2 units of insulin to clear any air from the pens before administration. In an interview, staff member M admitted to not knowing about the priming process, as it was her first day at the facility after working at another long-term care facility. The facility's policy clearly states that a 2-unit dose of insulin must be dialed and released as an air shot prior to administering each prescribed dose.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services for a dependent resident, leading to the resident feeling unsafe, dirty, and embarrassed. The resident, who was admitted for rehabilitation to increase strength, experienced a lack of assistance from staff in moving in bed, long wait times for call light responses, and no help with toileting needs. The resident reported wearing the same underwear throughout the stay and not having a bedside commode, which resulted in being told to hold bowel movements. Upon discharge, the resident was admitted to a critical access hospital with open, bleeding sores on the buttocks, indicating a lack of proper care during the stay. Interviews with staff revealed that while the scheduling was consistent, not all residents knew to use their call lights, necessitating regular check-ins by staff. Despite this, the resident reported that staff did not assist with repositioning or transfers, and the urinal was not emptied. The resident's admission records indicated a need for extensive assistance with mobility and personal care, yet these needs were not met, resulting in skin integrity issues and a feeling of mistreatment. The resident's cognitive patterns were intact, and the baseline care plan included interventions for repositioning and peri-care, which were not adequately implemented.
Inadequate Infection Control Practices by Staff Member
Penalty
Summary
Staff member M failed to perform proper hand hygiene and use protective measures during medical procedures for a resident. Observations revealed that staff member M did not sanitize her hands upon entering or exiting the resident's room, nor did she don gloves during blood glucose monitoring, insulin administration, or the administration of eye drops. Additionally, she placed the glucometer and supplies directly on the resident's overbed table without a protective barrier and failed to clean the glucometer after use, which was then stored without disinfection. Interviews with staff members indicated that the facility's policy requires hand hygiene before entering and exiting a resident's room, and the use of gloves during specific procedures. The policy also mandates the use of MicroKill wipes for cleaning glucometers shared among residents. Staff member M admitted to not following these protocols due to being in a rush and was unaware of the proper cleaning method for the glucometer. This oversight had the potential to increase the risk of spreading bloodborne pathogens among residents.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to ensure a clean environment for 10 of 14 sampled residents, leading to feelings of discouragement and frustration among residents. Observations revealed soiled diapers left in rooms, dirty floors, and food wrappers under beds. Specific instances included dirt-like clumps on the floor, dried coffee spills in hallways, and multiple dried liquid spots. Interviews with staff members indicated that housekeeping was short-staffed, resulting in rooms going uncleaned for several days, especially on weekends and after 3:30 p.m. Residents reported not seeing their rooms cleaned or bed sheets changed for several days. Resident #3's room had crumbs, debris, a soiled bed pad, and a broken sink handle. The resident's clothes were piled up, and a food tray was left from breakfast. The resident expressed frustration and discouragement, stating that complaints about these issues had not been addressed. The resident's Annual MDS showed a BIMS of 15, indicating cognitive intactness. A grievance report from the resident dated 3/5/24 highlighted concerns about unemptied garbage and unswept floors. The facility's policy on Resident Environmental Quality emphasized maintaining a safe, functional, sanitary, and comfortable environment, which was not upheld in this case.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned fall interventions for a resident identified as being at risk for falls. The resident's care plan included specific interventions such as ensuring adequate lighting, appropriate footwear, the use of a fall mat, and the addition of non-slip strips to the floor. However, during an observation, the resident was found sitting on the floor with no footwear, in a dimly lit room, and without the non-slip strips or fall mat in place. The floor was wet with urine, and the resident's sheets were soaked, indicating a lack of a structured toileting plan. Interviews with staff revealed that the care plan was not followed due to various reasons, including the removal of the fall mat, which was considered a tripping hazard, and a delay in applying the non-slip strips. The staff also indicated that the MDS coordinator was responsible for updating care plans, but there was no clear explanation for the failure to implement the planned interventions. The facility's policy on comprehensive, person-centered care plans was not adhered to, resulting in the resident's increased risk of falls and inadequate care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent a fall for a resident with a history of falls and severely impaired cognition. The resident had seven falls within a two-month period, including a fall resulting in a distal clavicle fracture and another fall causing a 4 cm laceration to the scalp. On the day of the incident, the resident was found sitting on the floor, barefoot, in a dimly lit room with wet urine on the floor and soaked bedsheets. The resident was not wearing a brief or bottoms, and the floor lacked non-skid strips or a fall mat. Interviews with staff revealed inconsistencies and failures in implementing the resident's fall prevention interventions. Staff members mentioned that the resident was supposed to wear footwear and have a fall mat by her bed, but these measures were not in place at the time of the fall. Additionally, there was a lack of communication and follow-through regarding the installation of non-skid floor strips, which had been requested but not completed. The resident's care plan included specific interventions to prevent falls, such as ensuring adequate lighting, appropriate clothing, and the use of non-skid slippers, but these were not consistently followed, leading to the resident's fall and injury.
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A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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