Life Care Center Of Plainwell

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a legal guardian’s right to make medication treatment decisions for a resident who was severely cognitively impaired and unable to make his own decisions. The resident was admitted with multiple diagnoses including legal blindness, heart failure, dysphagia, alcohol abuse, and kidney disease, and had a BIMS score of 6/15 indicating severe cognitive impairment. Guardianship paperwork identified two family members as co‑guardians. Despite this, the resident was started on quetiapine 50 mg twice daily via tube for behavior following hospital discharge, based on a hospital discharge summary that noted quetiapine had been started for agitation with good response. A medication informed consent form for quetiapine dated shortly after admission documented verbal consent “on the phone” without listing any name under resident/legal representative, left the reason for the prescription blank, and was signed only by a facility representative. The facility also obtained and implemented orders for clonazepam without clearly documented, valid consent from the co‑guardians and in conflict with one guardian’s stated wishes. A medication informed consent form dated several days after admission documented verbal consent from one guardian for clonazepam 0.25 mg BID for anxiety, with side effects including sedation and drowsiness, and was signed only by an RN. Another consent form dated later listed both guardians’ names for an increased clonazepam dose but did not include a dosage, and again lacked the guardians’ signatures. Progress notes show that clonazepam 0.25 mg BID was ordered by the medical director and later increased to 0.5 mg BID for anxiety due to restlessness and behavioral issues. A behavior note documented that a guardian was initially apprehensive about increasing clonazepam due to concern about sedation but, after discussion about the care plan and behaviors, stated they would follow the doctor’s recommendations and that a psychotropic consent was signed and filed, although the form itself did not contain the guardians’ signatures. Interviews with the co‑guardians and staff further demonstrated inconsistencies and lack of reliable consent practices. The co‑guardians stated they were clear that they did not want the resident sedated and specifically did not consent to quetiapine or clonazepam, and that they were not contacted on the dates the facility documented consents for these medications. One guardian reported telling the facility at a care conference that he did not want the resident sedated or “drugged,” while the SSD stated the guardians did not mention not wanting psychotropic medications. RN C reported he obtained verbal consent from one guardian for clonazepam but acknowledged the other guardian opposed the medication and that he entered a late progress note about the consent at the DON’s direction weeks later. RN F reported he completed the consent form for the clonazepam dose increase and that the guardian was reluctant due to fear of sedation. The DON stated that verbal consents were documented on forms and that physical signatures were not obtained because the guardians did not visit often, and confirmed that once verbal consent was obtained, they did not pursue physical signatures. The visitor log showed the guardians did visit on at least two dates during the relevant period, but no signed consents from them were present in the record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify a resident’s legal guardians of a fall and change in condition. The resident was admitted with diagnoses including legal blindness, heart failure, dysphagia, alcohol abuse, and kidney disease, and had a BIMS score of 6/15 indicating severe cognitive impairment. Guardianship paperwork identified two family members as co‑guardians. A progress note documented that the resident was found on his knees facing his bed at 0640 with oxygen and tube feeding tubing wrapped around him. He was assessed for injuries with none noted, assisted back to bed, tubing straightened, and vital signs and neuro checks initiated. The note also indicated the resident continued with fast breathing, initially high blood pressures that decreased throughout the day, frequent calling out, and no complaints of pain or bruising to the knees. A fall report for the same event described the resident as observed on his knees leaning over the bed with tube feeding and Foley catheter in place and without his nasal cannula. The resident was described as restless, dressing, and exhibiting compulsive behavior of calling out and self‑transferring between chair and bed despite staff encouragement to allow assistance. The fall report listed the physician and DON as notified but did not document family notification. In interview, the RN who worked that day stated she assumed the resident fell, notified the physician and DON, but could not remember if she notified the guardians. In a separate interview, both co‑guardians stated they were unaware of the fall and had not been contacted about it. The facility’s policy, reflecting federal regulations on notification of changes, requires immediate notification of the resident representative when there is an accident involving the resident that results in injury and has potential for requiring physician intervention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to manage a resident’s behaviors with individualized, non‑pharmacological interventions before initiating and escalating psychotropic medications. The resident was admitted with legal blindness, heart failure, dysphagia, alcohol abuse, kidney disease, and severe cognitive impairment (BIMS score 6/15). Upon admission, the resident was prescribed Seroquel 50 mg twice daily via tube for behavior, and later clonazepam was added and increased to manage behaviors. The facility’s own psychotropic medication policy required a thorough assessment of underlying causes of behaviors, use of person‑centered non‑drug interventions, and involvement of the resident or representative in discussions of non‑pharmacologic and medication interventions prior to psychotropic use. Behavior documentation over a 30‑day lookback showed only two days of disruptive sounds, while progress notes described frequent behaviors including yelling out "hey" repeatedly, persistent requests for water despite NPO status, drinking from the sink, toilet, and urinals, pulling out the G‑tube multiple times, and removing oxygen. The care plan identified a behavioral problem related to drinking water from his and his roommate’s urinals and from the toilet, and noted a history of non‑compliance with fluid restriction. The listed interventions were generic statements such as anticipating and meeting needs and educating the resident/family on coping and interaction strategies, but no specific, individualized intervention strategies were documented for this resident. Progress notes described staff reminding the resident about NPO status and attempting to orient him, but did not document a range of individualized non‑pharmacologic approaches trialed and evaluated prior to starting or increasing psychotropic medications. Interviews with multiple RNs indicated that the resident had daily behaviors such as yelling out, non‑compliance with NPO and oxygen, and pulling out his feeding tube, and that staff did not know of effective interventions beyond checking on him. The Social Services Director and DON acknowledged the resident’s frequent calling out and impulsive behaviors, and the DON stated that multiple interventions such as activities and regular checks were tried, but these were not reflected as specific interventions in the care plan. The family/guardians reported that although the facility called them about behaviors and held a care conference, they were not asked about non‑pharmacologic interventions and one guardian stated he told the facility he did not want the resident sedated despite behavior problems. The psychotropic medication policy required that psychotropic medications be used only after non‑drug approaches were attempted and that the prescriber conduct and document a comprehensive assessment demonstrating the necessity of the medication; the record showed initiation and dose increase of clonazepam for behaviors and anxiety without documented evidence of such comprehensive assessment or of systematic, individualized non‑pharmacologic interventions preceding the psychotropic use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and monitor ordered and needed skin care for a cognitively intact resident with fragile skin and multiple comorbidities, including morbid obesity, difficulty walking, heart failure, and chronic pain. The resident had an existing care plan problem for skin tears and fragile skin with an intervention to use caution during transfers and bed mobility. On 3/9/2026, during CNA-assisted toileting in preparation for going to the hospital, the resident reported dizziness, was lowered to the floor, and sustained skin tears to both upper arms and injuries to the backs of both hands and the right elbow. Nursing documentation noted hypotension and bradycardia, that the resident was assisted back to bed with a Hoyer lift, and that the physician would be notified of the low blood pressure. However, the weekly skin assessment and wound observation documentation did not address the new skin tear from 3/9/2026 in a timely manner. Subsequent provider and family reports showed that the dressing applied to the left arm skin tear was not changed for an extended period. The resident’s family member observed on 3/21/2026 that the bandage on the left arm was still dated 3/10/2026 and reported it had not been changed until she brought it to the nurse’s attention, by which time the arm was worse and weeping. A provider note on 3/21/2026 documented that the resident had sustained a fall the prior week, that the left forearm skin tear had been treated, but the dressing had not been changed since, and that when the dressing was removed the tear reopened with moderate bleeding, with the area reddened and bruised throughout the entire forearm. A later progress note on 3/25/2026 described the wound as a skin tear from blisters opening on the forearm due to fluid overload in the left arm related to heart failure, with the arm dependent and requiring elevation. These findings demonstrate that ordered and necessary skin care and dressing changes were not consistently implemented or monitored for this resident’s skin tear.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to follow the ordered infection prevention and control precautions for a resident diagnosed with RSV. The resident had physician orders for contact and droplet isolation precautions starting 4/7/2026, and progress notes documented RSV-positive results with isolation per policy. On 4/8/2026, signage outside the resident’s room indicated Enhanced Barrier Precautions and Droplet Precautions, instructing that staff must clean their hands before entering and leaving, and that providers and staff must wear gloves and a gown for specified high-contact resident care activities, as well as ensure eyes, nose, and mouth are fully covered before room entry and remove face protection before room exit. Despite these posted precautions and the resident’s RSV diagnosis, the Infection Preventionist entered the resident’s room wearing only a mask and did not don a gown or gloves, and then exited the room and continued down the hallway wearing the same mask. In an interview, the Infection Preventionist acknowledged being new to the role, confirmed awareness that the resident had RSV and that the signs were posted to direct staff on appropriate PPE, and stated that she should have worn a gown, gloves, and changed her mask but did not think about PPE because she was only in the room briefly. In a subsequent interview, the Infection Preventionist and the DON both stated that RSV required contact and droplet precautions, including gown, gloves, and mask, with eye protection described as optional, confirming that the PPE actually used by the Infection Preventionist did not meet the required precautions for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by extended call light wait times, negative staff comments, and lack of appropriate staff education. One resident with critical illness myopathy and end stage renal disease reported frequent delays of 30-45 minutes for call light responses, overheard staff referring to him as 'cranky,' and felt staff were retaliating against him after voicing concerns. The resident expressed feelings of anger, frustration, and being dehumanized, and stated that previous complaints to management were not addressed, leading him to stop reporting issues. Another resident with hemiplegia following a stroke, who required assistance with bed mobility and personal hygiene, reported waiting at least 30 minutes for staff to answer her call light. She described experiencing pain while waiting to be repositioned and discomfort from remaining in a soiled brief for extended periods. This resident stated that the delays made her feel sad and angry. A third resident with anxiety and depression also reported long call light wait times, particularly at night and on weekends, sometimes waiting so long that her needs went unmet and she fell asleep without assistance. Staff interviews confirmed that residents had complained about long call light wait times, especially during the night shift. Resident council meeting minutes and a confidential group interview further corroborated that multiple residents experienced extended wait times, with reports of waiting over 45 minutes during evening hours across several facility halls. The facility's own dignity policy emphasized the importance of treating residents with respect and enhancing their self-worth, but the lack of recent staff education and the ongoing issues with staff-resident interactions contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to protect a resident's right to be free from physical abuse, resulting in one resident physically assaulting another. The incident involved a male resident with schizophrenia and autism, who had a documented history of aggressive behaviors, including hitting, biting, and throwing objects at both staff and other residents. Despite multiple documented episodes of aggression in the weeks leading up to the incident, no new interventions or increased supervision were implemented to address the escalating behaviors. On the day of the incident, the aggressive resident exited his room and struck another male resident, who was cognitively intact and using a wheelchair, in the face. Staff interviews confirmed that there was no staff present in the hallway or at the nurses' station at the time of the assault, and that the aggressive resident was able to approach and hit the other resident without intervention. The assaulted resident sustained redness to his cheek, and the aggressor incurred a minor laceration from contact with the wheelchair. Prior to the assault, the aggressive resident had also thrown a drink at another resident, but the facility did not increase supervision or implement additional safety measures following this event. The care plan for the aggressive resident noted his history of physical aggression but was not updated with new interventions after repeated incidents. Documentation also revealed that required 15-minute checks, which were eventually added to the care plan, were not consistently performed or documented.

Plan Of Correction

Resident #102 still resides in the facility. The resident has not had any further encounters with other residents and continues to show no signs of distress from the 5/12/25 and 6/17/25 incidents. Resident #101 still resides in the facility and has not had any further issues of aggression with other residents. Facility residents have the potential to be affected by the alleged deficient practice. The Social Services Director/designee completed facility-wide interviews with residents to ensure there were not any unaddressed concerns on 7/1-7/3/25. Any discrepancies noted with the interviews were addressed at that time. The Staff Development Coordinator/Designee will provide re-education to all staff on the facility abuse prevention policy and de-escalation tips for challenging behaviors on or before 7/14/25. Staff will not be allowed to work until education is completed. The IDT will review 24-hour reports for resident-to-resident encounters for potential abuse. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. The Social Service Director/Designee will audit resident concerns to review for potential abuse allegations during IDT meetings. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Executive Director is responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing staff, specifically a Certified Nursing Assistant (CNA), had the appropriate skill sets and completed required annual trainings, as mandated by facility policy and federal regulations. The facility's policy required all staff to receive training on dementia care upon hire, annually, and as needed, with the Staff Development Coordinator responsible for maintaining training records. However, review of training records revealed that one CNA had not completed 60 out of 62 required trainings over a 13-month period, including essential topics such as dementia care, challenging behaviors, and mental health in LTC. The facility assessment indicated that dementia and cognitive impairment were prevalent among residents, with 19 residents diagnosed with dementia in the previous two quarters, and all staff were expected to be trained in these areas. An incident occurred in which a resident with dementia began yelling in the hallway. The CNA in question, who had not completed the required dementia care training, responded by pulling the resident's gown up to cover his mouth and then spraying an aroma therapy mist toward the resident's face, which also affected another CNA present. This action caused the resident to become more agitated. The CNA later admitted to being stressed by the resident's behaviors and confirmed she did not recall receiving any dementia care training from the facility. The other CNA present reported that the actions taken by the untrained CNA escalated the resident's distress. Interviews with facility leadership, including the Staff Development Coordinator, Human Resources Director, and Nursing Home Administrator, confirmed that staff completion of required trainings had not been monitored until recently. Staff were only able to complete computer-based trainings while in the facility, and there were reported difficulties accessing available computers. The facility had no documentation of the CNA attending any in-person dementia care training during her employment, aside from initial orientation. This lack of training and oversight resulted in the potential for delivery of care that did not support the resident's highest practicable well-being.

Plan Of Correction

Resident #103 no longer resides at the facility. CNA S no longer works at the facility. Facility residents have the potential to be affected. The DON/Designee conducted an audit to identify CNAs who have not completed Dementia training on 7/2/25. The Staff Development Coordinator/Designee will educate licensed nurses and certified nursing aides on education and training requirements and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. CNA s will be required to have completed at least 2 dementia-related training courses within the past 12 months prior to 7/14/25. The DON/Designee will conduct weekly audits of CNA education assignments to ensure that education is being completed. The audit will be conducted one time per week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia did not receive individualized care interventions as outlined in their care plan. The resident, who had a BIMS score indicating severe cognitive impairment and a history of dementia and cognitive communication deficit, was subjected to actions by a CNA that were not authorized or tailored to their needs. The care plan specified approaches such as allowing extra time for responses, using simple instructions, and providing cues, but these were not followed during the incident. On the night in question, the resident became agitated and began yelling in the hallway. A CNA responded by pulling the resident's gown up over their mouth and spraying an aroma therapy mist directly at the resident's face, actions which were not part of the resident's care plan and had no physician order. This intervention caused the resident to become further agitated, resulting in physical resistance and distress. Other staff members witnessed the incident and reported that the resident only calmed down after alternative, individualized calming strategies were used. Interviews with staff revealed that the CNA had not received required dementia care training and had independently brought the aroma therapy spray into the facility without authorization from nursing or medical staff. Multiple staff members confirmed that the use of aroma therapy mist was not approved or ordered for any residents, and the facility's policy required individualized, person-centered interventions for dementia care. The facility also had not been monitoring staff compliance with required dementia care training at the time of the incident.

Plan Of Correction

Resident #103 no longer resides in the facility. Facility residents with a diagnosis of dementia have the potential to be affected. The DON/Designee conducted an audit to identify those residents who have been diagnosed with dementia and were reviewed by the Interdisciplinary Team for appropriate interventions. Their personalized care plans will be reviewed for accuracy on or by 7/11/25. The SDC/Designee will educate nurses and CNAs on the Caring for Dementia policy, creating and following individualized care plan interventions, 10-Tips to De-Escalate Challenging Situations, and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. The DON/designee will complete audits three times a week for eight weeks or until substantial compliance is achieved of newly admitted and readmitted residents with a dementia diagnosis to ensure their care plan includes individualized interventions. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate and resolve grievances for a resident who reported a missing wedding ring. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported the loss of his wedding ring several months ago. The concern was documented by the Social Services Director, who noted that the resident had reported the missing item to her. The investigation was assigned to the Central Supply Director, who conducted a search in the resident's room but did not find the ring. However, the investigation was incomplete as the actions taken to resolve the concern, the date and time of findings, and the executive director's signature were left blank on the concern form. Interviews with the Social Services Director and the Executive Director revealed that the facility's grievance process was not followed through to completion. The Social Services Director stated that the concern forms are initially handled by her and then passed to the appropriate department head, who is responsible for resolving the issue before it is reviewed and signed off by the Executive Director. However, in this case, the completed concern form was not returned to the Social Services Director, and the Executive Director acknowledged that there was no follow-up completed on the missing ring. This lack of follow-through resulted in the resident's grievance remaining unresolved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a kitchen tour. A full pan containing two beef roasts was found in the walk-in cooler with a vented top, and the Food Service Director (FSD) was unable to provide a cooling log for the item, stating it was erased during cleaning. The roast was cooked the previous day and placed in the cooler at a temperature between 160F and 170F, but the FSD was unaware of the required time and temperature for proper cooling. The roast was eventually discarded due to uncertainty about its cooling process. Additional issues were noted with expired quaternary ammonium test strips, which are necessary for measuring sanitizing solution concentrations. The FSD acknowledged that both the current and backup test strips were expired. Furthermore, the kitchen was found to have cleanliness issues, including crumb debris in utensil drawers, debris on muffin tins, and black debris on can openers. A bus tub with kitchen equipment contained a dead moth and sticky debris, indicating a lack of regular cleaning and maintenance. The dish machine area also presented problems, with the machine running below the required 160F for the wash cycle, as indicated by the manufacturer's data plate. The dish log showed that 19 out of 24 logged wash temperatures were below the required minimum. Additionally, the physical facilities, such as the floor juncture under the dish machine and the dry storage room, were found to have accumulations of dirt and grime, further highlighting the facility's failure to maintain a clean and safe food service environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies in hand hygiene and glove use during resident care. In one instance, a cognitively intact resident with a pressure ulcer and catheter care orders was observed receiving care from a hospice RN and CNAs who repeatedly failed to perform hand hygiene between glove changes. The RN handled soiled briefs and bed linens, touched the resident's urinary catheter, and managed wound care without proper hand hygiene, increasing the risk of cross-contamination and infection. Additionally, the facility did not ensure the proper cleaning and disinfecting of resident equipment. Observations revealed that tube feeding pumps, poles, and bases for two residents were splattered with dried formula and debris, indicating a lack of routine cleaning. Housekeeping staff confirmed that these items were part of a monthly deep clean list, but the visible dirt and debris suggested that cleaning protocols were not being followed consistently. The facility also failed to implement Enhanced Barrier Precautions (EBP) as required. A resident with a stage 3 pressure ulcer and a history of multidrug-resistant organisms was observed receiving care without the CNA wearing a gown, despite signage indicating the need for such precautions. Furthermore, during wound care, an LPN placed soiled dressing supplies into a clean field and failed to perform hand hygiene before applying gloves, compromising the sterile environment necessary for wound care. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation of advance directives for a resident with multiple sclerosis, who was cognitively intact. The resident's medical record contained a document indicating no advance directives were chosen at the time, yet an order summary and care plan indicated a DNR status with comfort measures was active. However, a physical chart at the nurse's station incorrectly displayed a 'Full Code' status. Interviews with nursing staff revealed inconsistencies in the process of updating and validating code status changes, with a lack of proper documentation and signatures from witnesses and the physician. Further investigation showed that during a hospital readmission, a conversation about the resident's code status change was reportedly held, but no documentation was found to support this. The Social Services Director indicated that the nursing department handles advance directives, but no documentation was found in the resident's medical record to confirm the resident's DNR wishes. The facility's policy requires review and documentation of advance directives upon admission, quarterly, and when there is a change in the resident's condition, but this was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide bed-hold notifications to residents who were transferred to the hospital, as required by their policy. This deficiency was identified for two residents, Resident #41 and Resident #2, who were hospitalized without receiving the necessary bed-hold forms. Resident #41, who was readmitted to the facility with diagnoses including surgical aftercare and shoulder pain, was sent to the emergency room due to a leaking abscess and deep vein thrombosis. However, there was no evidence in the medical record that a bed-hold notice was provided for this hospitalization. The Director of Nursing confirmed that the facility was unable to locate the form for Resident #41's hospitalization. Similarly, Resident #2, who was cognitively intact and had diagnoses including Parkinson's, seizures, bipolar disorder, and schizophrenia, was transferred to the hospital six times in 2024 without receiving a bed-hold form. During interviews, both the Director of Nursing and the Unit Manager acknowledged that bed-hold notifications should be provided with each hospital transfer. However, the forms were not found in the resident's medical records or the facility's filing system. Medical Records staff also confirmed that no bed-hold forms were uploaded into the electronic medical records for Resident #2.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise a person-centered care plan for a resident, resulting in an inaccurate reflection of the resident's current care needs. The resident, who was cognitively intact with a BIMS score of 15/15, had a diagnosis of a stage 3 pressure ulcer in the sacral region. Initially, the care plan included an intervention for an indwelling catheter, which was initiated on 9/4/2024. However, observations and interviews revealed discrepancies in the care plan. On 10/8/2024, the resident was observed without a urine drainage bag, and subsequent notes indicated that the wound vac and foley catheter had been discontinued by 9/20/2024. Further observations and interviews confirmed that the resident was incontinent of bowel and bladder and did not have a foley catheter at the time of the survey. Despite these changes, the care plan still included an intervention for an indwelling catheter, which was no longer applicable. The Licensed Practical Nurse Unit Manager confirmed that the care plan should have been updated to reflect the resident's current condition, indicating a failure in maintaining an accurate and up-to-date care plan for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently provide restorative exercises as recommended for a resident with hemiplegia and hemiparesis following a stroke, resulting in the potential for pain, stiffness, and avoidable decline. The resident, who was cognitively intact, reported receiving therapy initially but was now dependent on restorative exercises due to insurance limitations. The restorative program was developed by therapy and was supposed to be administered by a Restorative Aide and overseen by a Restorative Program Nurse. However, the resident received restorative exercises only 6 times out of 24 opportunities over an 8-week period. This inconsistency was attributed to the Restorative Aide having days off and being reassigned to work as a CNA, with no coverage for her restorative duties. The Restorative Program Nurse confirmed the inconsistency and acknowledged that the facility had identified the issue during an audit, but a plan to address it was not yet fully implemented.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, resulting in the potential for urinary tract injury and/or infection. The resident, who was cognitively intact and dependent on staff for activities of daily living due to obstructive uropathy, had an indwelling catheter that was observed to be leaking. During observations, the resident's brief and bedding were found saturated with urine, and the urine collection bag contained dark red urine. Certified Nursing Assistants reported that the catheter had been leaking for some time and had not been changed, despite the knowledge of the nursing staff. The Director of Nursing was unaware of the catheter leakage issue, and the Unit Manager mentioned discussions about removing the catheter to allow the resident to urinate naturally, but no action had been taken. A previous progress note indicated that the catheter had been changed due to leaking several months prior. The facility's procedure for catheter care emphasized monitoring for complications, maintaining a sterile closed system, and replacing the catheter when leakage occurs, but these protocols were not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and address Post Traumatic Stress Disorder (PTSD) triggers for a resident, leading to a lack of trauma-informed care. The resident, who had a diagnosis of PTSD, dementia with psychotic disturbance, adjustment disorder, and obsessive-compulsive disorder, did not have a care plan that included focus, goals, or interventions related to PTSD or any possible triggers. Despite the resident's severe cognitive impairment and history of abuse, there was no trauma-informed care assessment conducted after the PTSD diagnosis, and staff members, including LPNs and the Social Services Director, were unaware of the resident's triggers. An incident occurred where another resident verbally threatened the resident with PTSD, which could have been re-traumatizing. The threatening behavior was reported, but repeated attempts to contact the witness were unsuccessful. Observations of the resident showed signs of distress, such as yelling out monosyllable noises, but staff interviews revealed a lack of awareness and documentation regarding the resident's PTSD and potential triggers. The Social Services Director confirmed that trauma assessments should be completed at admission and with new diagnoses, but this was not done for the resident in question.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the rights of residents to be free from abuse, as evidenced by incidents involving two residents. Resident #80, who was severely cognitively impaired, exhibited aggressive behavior towards her roommate, Resident #61. On one occasion, Resident #80 pulled her roommate from her wheelchair and restrained her on the floor, causing physical and emotional distress. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that Resident #80 was confused and believed Resident #61 was trying to leave the room for inappropriate reasons. Resident #61, who was moderately cognitively impaired and used a wheelchair for mobility, experienced fear and emotional distress following the altercation with Resident #80. The incident report and interviews indicated that Resident #61 was unable to comment on the event due to her cognitive communication deficit but expressed feelings of being stuck at the facility. The CNA described Resident #61 as being in shock and fearful after the incident, highlighting the emotional impact of the physical restraint. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse, including physical restraint by other residents. Despite this policy, the facility did not adequately prevent or address the aggressive behavior of Resident #80, resulting in a failure to protect Resident #61 from abuse. The report indicates that the facility's inaction in managing Resident #80's behavior and ensuring the safety of Resident #61 contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from mental and verbal abuse by staff, specifically involving three residents. Resident #102, who was cognitively intact, reported being verbally intimidated by a CNA who told her not to wet the bed while placing her on a bedpan. The resident's daughter corroborated this account, stating that the resident had been left on the bedpan all night. The resident had a history of stroke and was incontinent, which made her dependent on staff for toileting assistance. The facility's care plan for Resident #102 lacked specific interventions for toileting and skin integrity, which may have contributed to the incident. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unhelpful. He recounted an incident where a CNA refused to change his brief after multiple bowel movements, telling him he would have to wait for the next shift. This resident also reported that another CNA was stern and restrictive about his choice of sleepwear. The facility's documentation showed that a concern form was completed but not promptly addressed, and the CNA involved was eventually terminated. Resident #105, who was cognitively intact, expressed dread about the night shift due to the CNAs' behavior. She reported that a CNA was dismissive and intimidating, making her feel uncomfortable when requesting incontinence care. The facility's response to these complaints was inadequate, as there was no evidence of follow-up interviews with other residents or staff, and the concerns were not reported to the State Agency. The lack of timely and appropriate action by the facility's administration contributed to the deficiency in protecting residents from abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for continued violations involving mistreatment, neglect, or abuse going undetected, unreported, or without thorough investigation. Resident #102, who was cognitively intact, reported that a CNA had left her on a bedpan all night and made inappropriate comments. This incident was documented by RN D after being informed by the resident's daughter and the resident herself. However, the report was not immediately escalated to the State Agency. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unresponsive to his needs. He specifically mentioned an incident where a CNA refused to change his brief after multiple requests. This concern was documented by the Director of Rehabilitation but was not interpreted as an allegation of abuse or neglect by the DON, and thus, was not reported to the State Agency. Resident #105, who was cognitively intact, expressed dread about the night shift due to the behavior of the CNAs, particularly CNA G, who made dismissive comments. Despite multiple complaints from residents about CNA G, the Nursing Home Administrator did not conduct further interviews with other residents or staff, nor did they report the concerns to the State Agency. The lack of timely reporting and thorough investigation of these allegations constitutes a deficiency in the facility's handling of potential abuse cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately investigate and protect residents following allegations of abuse involving three residents. Resident #102, who was cognitively intact, reported that a CNA had been rough, yelled at her, and left her on a bedpan all night. Despite the report being made, the CNA was not immediately suspended, and the investigation was incomplete. The facility's response was delayed, and the incident was not reported to the State Agency. Resident #103, who was cognitively impaired, reported that a CNA was rude and refused to change his brief during the night, telling him he would have to wait for the next shift. A complaint form was filled out, but the investigation and response were incomplete. The Director of Nursing (DON) did not interpret the complaint as an allegation of abuse or neglect and did not report it to the State Agency. The CNA was eventually terminated, but the process was delayed, and the investigation was not thorough. Resident #105, who was cognitively intact, reported that the night shift CNAs were not nice, with one CNA being intimidating and another acting annoyed when asked for assistance. The facility did not follow up with the residents or report the concerns to the State Agency. The Nursing Home Administrator admitted to not interviewing other residents or staff and not reporting the concerns, resulting in an incomplete investigation and potential for future mistreatment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement care plan interventions to prevent the development of pressure ulcers for a resident, resulting in a Stage 2 pressure ulcer on the right buttock and a deep tissue injury on the coccyx. The resident, who was admitted with a history of stroke and was cognitively intact, was identified as being at moderate risk for pressure ulcers due to limited mobility, incontinence, and other factors. Despite these risks, the resident's care plan did not include necessary interventions for skin integrity and pressure ulcer prevention. The resident developed moisture-associated skin damage (MASD) and subsequently a Stage 2 pressure ulcer, which were not addressed in the care plan or assessed by a physician before the resident's discharge. Interviews with facility staff revealed that the resident was left on a bedpan overnight, which may have contributed to the skin damage. The resident's family member reported that the resident was immobile and incontinent, and had been treated roughly by a CNA. The Director of Nursing was unable to provide additional information on why appropriate interventions were not in place. The lack of documentation and failure to update the care plan contributed to the development of the pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain professional standards of care and provide adequate incontinence care for two residents, resulting in moisture-associated skin disorder (MASD). Resident #102, who was cognitively intact but immobile due to a recent stroke, was admitted without a care plan addressing her incontinence and skin integrity needs. Despite being at moderate risk for pressure wounds, no interventions were in place, leading to the development of MASD and a Stage 2 pressure ulcer. Reports indicated that Resident #102 was left on a bedpan overnight, which may have exacerbated her condition. Resident #106, also cognitively intact, reported developing a painful open area on her buttocks due to her incontinence brief not being changed throughout the day. Despite having a care plan indicating a risk for skin breakdown, there were no person-centered interventions for her incontinence care needs. The resident's call light was reportedly ignored by CNAs, and her incontinence task record showed frequent incontinence episodes. A physician's order for MASD treatment was incomplete, lacking a medication name, and staff were unaware of the resident's MASD concerns until the surveyor's intervention. Interviews with facility staff revealed a lack of awareness and appropriate response to the residents' incontinence care needs. The LPN responsible for Resident #102's admission failed to develop a baseline care plan, and the Director of Nursing could not provide additional information on why interventions were not in place. For Resident #106, the LPN was unaware of the MASD issue and had to correct the treatment order after the surveyor's inquiry. These deficiencies highlight a systemic failure in providing adequate incontinence care and maintaining skin integrity for residents at risk.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely monitoring of weight for a newly admitted resident, Resident #105, who was at risk for malnutrition. According to the facility's policy, a resident's weight should be recorded at the time of admission, weekly for four weeks, and then monthly. However, Resident #105's weight was not monitored weekly as required. The resident was admitted with a diagnosis of malnutrition and adult failure to thrive, and the care plan included monitoring for significant weight loss. Despite this, there was no record of weights taken between the initial weight of 144.1 pounds on 6/9/24 and a subsequent weight of 134.3 pounds on 7/1/24, indicating a 6.8% weight loss in three weeks. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for ordering and monitoring weekly weights. The Registered Dietician (RD) was aware of the resident's risk for malnutrition but did not know if weights were monitored weekly. The Licensed Practical Nurse (LPN) stated that newly admitted residents are weighed weekly, but this was not done for Resident #105. The Director of Nursing (DON) confirmed that the nurse responsible for the resident's admission should ensure weight monitoring orders are in place, but this was not done for Resident #105, leading to a delay in identifying significant weight loss.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive care plan for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination. The resident was observed multiple times in positions that did not align with the care plan interventions, such as leaning to the right side in bed without assistive devices or pillows for proper body alignment. The resident's care plan included the use of a lateral wedge cushion and assistance with eating and drinking, but these measures were not observed during the surveyor's visits. Additionally, the resident was seen in a Geri chair in positions that were uncomfortable and lacked proper support, such as a hyper-extended neck and leaning to the left without adequate positioning aids. Despite the care plan's directives, the staff did not utilize assistive devices or reposition the resident to ensure comfort and alignment. Interviews with the Director of Nursing revealed that the staff did not adhere to the facility's policies and procedures for repositioning residents, which contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a dependent resident, identified as Resident #102, had access to fluids for hydration, resulting in the potential for dehydration. Resident #102 had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact with a BIMS score of 13/15. Observations on multiple occasions revealed that Resident #102's over-the-bed table, which held water and meal trays, was consistently placed out of reach, leading to dry and cracked lips, a sign of dehydration. During one observation, Resident #102 was found with a wet shoulder and an empty styrofoam cup, indicating an attempt to drink water that resulted in spillage. Interviews with staff revealed that the CNA responsible for water pass did not provide Resident #102 with the appropriate sip cup, despite the care plan indicating that all drinks should be in sip cups. The Director of Nursing stated that water should be passed to every resident at least twice a day and that residents should always have access to drinkable water. However, the facility's policy on hydration and nutrition, which mandates that fluid is available to residents at all times, was not adhered to, as evidenced by the repeated observations of Resident #102 without accessible fluids.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide assistive devices as ordered for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination, which resulted in the potential for a decline in oral intake of food and fluids. The resident was cognitively intact and had specific physician orders for a regular diet with all drinks in sip cups and a plate guard. However, during multiple observations, the resident was found without the necessary assistive devices, such as sip cups and plate guards, during meals. The resident's care plan also indicated a risk for dehydration and required assistance with eating and drinking, which was not adequately provided. Observations revealed that the resident was often in positions that compromised her ability to eat and drink effectively, such as leaning to one side in bed or in a reclined Geri chair without proper support or positioning aids. Interviews with staff, including a registered dietician and certified nurse assistants, confirmed that the resident was not receiving the prescribed assistive devices. The water pass census indicated that the resident required a sip cup, but staff provided a styrofoam cup instead, which the resident could not use effectively. These failures in providing the necessary assistive devices and positioning support contributed to the deficiency identified by the surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement infection control enhanced barrier precautions for a resident, leading to the potential for the spread of infection. The resident had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact. The resident's care plan and physician orders required enhanced barrier precautions, including the use of gowns and gloves during personal care due to the presence of a foley catheter and g-tube. However, during observations, staff members were noted not adhering to these precautions. Specifically, a CNA was observed providing personal care without wearing the required personal protective equipment (PPE), and another CNA performed catheter care without donning a gown, despite the signage indicating the need for such precautions. Interviews with staff, including CNAs, an LPN, the RN/Infection Preventionist, and the Director of Nursing, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents requiring enhanced barrier precautions. The facility's policy on enhanced barrier precautions, reviewed on a specific date, also outlined the necessity of using gowns and gloves during high-contact care activities for residents with indwelling medical devices. Despite these guidelines, the staff did not consistently follow the required infection control measures, as evidenced by the observations and interviews.