Failure to Notify Physician of Residents’ AMA Discharges
Summary
The deficiency involves the facility’s failure to follow its policy requiring prompt notification of the attending physician or provider when a resident leaves against medical advice (AMA). For one resident admitted with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed moderately impaired cognition on the most recent MDS, with independence in eating, partial assistance with toileting, substantial assistance with bathing, and setup for personal hygiene. On the day of discharge, the resident’s BIMS score was 13, indicating cognitively intact status, and the resident signed an Unauthorized Discharge Release of Responsibility form to leave AMA after the facility documented discussion of the risks and attempts to have the resident remain. However, the Medical Director/provider was not notified of this AMA discharge, and the Medical Director later confirmed he had never been informed. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential HTN, had an MDS indicating independence with eating, dependence on staff for toileting and bathing, and partial assistance with personal hygiene. This resident was discharged AMA by the resident’s Guardian, as documented in a progress note. Review of the medical record revealed no documentation that the Medical Director/provider was notified when the resident left AMA, and the Regional Clinical Director confirmed that the provider was not notified at that time. The facility’s written policy titled “Discharging a Resident Without a Physician’s Approval” states that when a resident or representative requests discharge earlier than outlined in the care plan and without physician approval (AMA), the attending physician or provider is to be promptly notified. The failure to notify the physician/provider for both AMA discharges constituted non-compliance and was cited under Complaint Number 2699059.
Penalty
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The facility did not maintain an adequate supply of clean linens for all residents on one floor, leaving staff with only a few towels and no washcloths available during morning care. CNAs reported that this shortage was a daily issue and that they sometimes used towels or pillowcases in place of washcloths to wash residents because linens were not restocked from laundry until later in the morning. The sole laundry aide acknowledged that linens sometimes ran out before they could be washed and restocked, while the housekeeping/laundry supervisor stated that although there were enough linens overall, there was not enough staff to keep them clean, contrary to the facility’s policy requiring clean bed and linens in good condition.
Two residents’ needs and preferences were not accommodated when one bariatric resident was repeatedly observed lying directly on a bare bariatric mattress without a fitted sheet due to a lack of bariatric linens on the units, and another resident who was cognitively intact with significant mobility impairments, and who had clearly documented preference for showers, received only bed baths for several months because the only shower bed was broken and missing key parts, as confirmed by staff and direct observation.
Surveyors found that two residents who depended on staff for ADLs and had cognitive impairment did not have their call lights within reach. One resident, who routinely lay on her left side facing the wall, had her call light cord wrapped around the right bed rail and hanging between the rail and mattress on multiple observations, and both an LPN and an RN had difficulty locating and repositioning it so the resident could reach it. Another resident in bed had a call light placed on a set of drawers several feet away and out of reach, which an RN confirmed.
A resident with intact cognition and multiple medical conditions, including lumbar spinal stenosis and acute cystitis, had documented care plan needs for assistance with ADLs and a stated preference that hygiene choices were very important. On one occasion, staff did not provide requested washing, citing lack of hot water in the resident’s room, even though hot water was available elsewhere in the facility. The resident’s family observed the lack of hot water, later received a call from the resident reporting that staff refused to wash her, and reported that staff dressed the resident without completing hygiene, causing the resident distress. This was inconsistent with facility policy requiring adequate nursing care and honoring reasonable resident requests.
A resident with multiple chronic conditions and intact cognition was started on Remeron 7.5 mg at bedtime for decreased appetite after an LPN observed reduced meal intake over several days and contacted the physician. The resident’s HCPOA had been formally designated and the paperwork submitted to the facility, but there was no documentation that this representative was notified of the new psychotropic medication or of the rationale for its initiation. The HCPOA later reported never being informed about the Remeron or any appetite issues, while the DON confirmed the absence of documentation and the LPN acknowledged she did not chart any notification despite stating she frequently spoke with the resident’s emergency contacts.
A cognitively intact resident with mobility limitations and multiple medical conditions had a care plan and posted schedule indicating showers on specific evenings and as requested, with sponge baths only when a full bath or shower could not be tolerated. Review of shower sheets, aide charting, and progress notes over a one‑month period showed missing documentation on some scheduled days and no evidence the resident received a shower or bed bath on those dates, nor that the resident refused showers or requested bed baths instead. During observation, the resident reported not having a shower for three weeks and only receiving bed baths, while an LPN and a CNA stated the resident was scheduled for evening showers on shifts they did not work and suggested staffing limitations related to the need for a mechanical lift and two‑person assist as a possible reason showers were not provided. This occurred despite facility policy stating residents have the right to make their own schedule and participate in decisions affecting their care.
Inadequate Supply and Availability of Clean Linens for Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean linen was available to meet residents' needs on the third floor, affecting all 46 residents residing there. During an early morning observation of the third-floor linen storage, surveyors found only six towels and no washcloths available for use. Certified Nursing Assistants reported that at the start of their shifts there were no linens available to wash and get residents up, and that this was a daily concern. Staff stated that linens were typically not brought up from the laundry until later in the morning, leaving them without appropriate supplies during morning care. CNAs reported that, due to the lack of linens, towels and even pillowcases were sometimes used instead of washcloths to wash residents. The laundry aide reported being the only laundry staff member on duty, working from early morning until mid-afternoon, and acknowledged that at times they ran out of linens before laundry could wash and restock. The housekeeping/laundry supervisor stated there was sufficient linen inventory but no one available at the facility to keep the linen clean. The facility’s Quality of Life policy stated that residents were to be provided with a safe, clean, comfortable, and homelike environment, including clean bed and linens in good condition, which was not met based on these findings.
Failure to Provide Appropriate Linens and Maintain Shower Equipment to Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences regarding bed linens. One resident with morbid obesity, knee dislocation, and impaired lower extremity function was observed twice on the same day lying directly on a bariatric mattress without a fitted sheet. The resident reported that the facility frequently ran out of fitted sheets, gowns, and towels, and stated she did not refuse linens but that they were not available. An LPN confirmed the resident was lying on a bare mattress. Inspection of the south hall linen area, the north linen closet, and the second floor revealed no bariatric fitted sheets available for staff use. In the laundry area, only two bariatric fitted sheets were eventually located after searching, and the DON confirmed there were no bariatric fitted sheets in the residential areas. The deficiency also includes failure to honor another resident’s stated bathing preference due to lack of functioning equipment. This resident, who had cerebral infarction, cellulitis, type 2 diabetes, morbid obesity, and significant upper and lower extremity impairments, was cognitively intact and care planned to have ADL assistance with honoring choices and preferences whenever possible. Facility documentation showed it was very important to this resident to choose between types of bathing, and he specifically preferred showers. However, shower records over a nearly three‑month period showed he received only bed baths. The resident reported he had not received a shower for two and a half to three months and was told by staff that the shower bed he required was broken. Observation confirmed the shower bed was missing pins that held the frame together, and staff, including an LPN and a CNA, stated the shower bed had been nonfunctional for weeks to a couple of months and was the only shower bed available, preventing the resident from receiving showers.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were within reach for residents who required assistance with activities of daily living. One resident with severe cognitive impairment, dementia, impaired balance, and dependence on staff for ADLs was care planned to have the call light within reach and required staff assistance for bed mobility and transfers via mechanical lift. On two separate observations, this resident was lying in bed on her left side facing the wall, with the bed positioned against the left wall, and the call light was not visible or accessible. The call light cord was wrapped around the right bed handrail and hanging between the handrail and mattress, and the resident stated she did not know where the call light was and could not reach it. An LPN and an RN both had difficulty locating the call light, needing to reach under the bed and follow the cord, and both confirmed that the resident typically lay on her left side facing the wall. Even after the RN attempted to reposition the call light on the right handrail, the resident was still unable to reach it. Another resident with moderate cognitive impairment, dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system required at least setup assistance for ADLs. During observation, this resident was in bed with the call light placed on a set of drawers approximately three feet from the bed and out of reach. The resident was not interviewable, and an RN confirmed the observation that the call light was not within the resident’s reach. These findings show that for both residents reviewed, staff did not ensure call lights were positioned so that residents could access them as required by their needs and care plans.
Failure to Honor Resident’s Personal Hygiene Preferences
Penalty
Summary
The facility failed to honor a resident’s stated preferences for daily personal care and hygiene. The resident was admitted with diagnoses including lumbar spinal stenosis with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression. An admission MDS dated 01/08/26 documented intact cognition with a BIMS score of 15 and indicated that hygiene choices were very important to the resident. The resident required supervision or touching assistance with ADLs, including bathing, and the care plan dated 01/04/26 identified ADL self-care needs related to deconditioning and weakness, with interventions to assist with personal hygiene. On 01/04/26, the resident requested to be washed, but staff did not provide the requested hygiene care, citing a lack of hot water in the resident’s room, despite hot water being available elsewhere in the facility. According to the DON, the resident’s family called on 01/05/26 with concerns that the resident had not been washed as requested the previous day due to the hot water issue. The family reported that during their visit they noted there was no hot water, and later the resident called them stating staff would not wash her for that reason. The family further stated that staff dressed the resident without completing any hygiene, which upset the resident. Facility policy on Resident Rights and Facility Responsibilities stated that residents had the right to adequate and appropriate nursing care and to have all reasonable requests honored.
Failure to Notify Resident Representative of New Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident representative when a psychotropic medication was initiated for a resident. The resident, who had intact cognition per the admission MDS, had multiple diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, and had been sent to the emergency room during the stay. Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, identified a family member as the HCPOA, and this information was submitted to the facility. On 09/19/25, a physician ordered Remeron 7.5 mg at bedtime for decreased appetite, but there was no documentation that the resident’s representative was notified of this new psychotropic medication. During interview, the HCPOA stated she was never informed that the resident was started on Remeron and believed that if he had decreased appetite, which she was never told about, it was likely related to pneumonia or a change in condition. The DON confirmed there was no documentation of the rationale for starting Remeron or of notification to the representative. The LPN who obtained the order reported she had observed the resident eating less than 50% of meals over a couple of days, did not want him to lose weight, and therefore called the physician for the Remeron order instead of consulting the dietitian, who was not present that day. She stated she had tried protein shakes from her medication cart, which the resident did not like, and that no other supplements were ordered. The LPN reported she was sure she had informed the emergency contacts about the Remeron but acknowledged she failed to chart this, and there was no documented evidence of notification in the record.
Failure to Honor Resident’s Shower Preferences and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with a cognitively intact resident’s stated preferences and care-planned interventions. The resident, admitted with diagnoses including cellulitis of the left lower limb, peripheral vascular disease, and major depressive disorder, had a care plan dated 03/06/25 indicating an ADL self-care performance deficit related to impaired mobility and muscle weakness. Interventions included providing bathing and showering per the shower schedule and as requested, and offering a sponge bath when a full bath or shower could not be tolerated. Physician orders dated 03/20/25 documented that the resident required a two-person assist with a mechanical lift. A Quarterly MDS assessment showed the resident required substantial to maximal assistance with toileting hygiene and bathing, was dependent for transfers and getting in and out of a tub or shower, and did not reject care during the seven-day look-back period. Record review of shower sheets and aide charting from 12/08/25 through 01/08/26 showed missing documentation for 12/08/25 and 12/18/25, with no evidence the resident received either a shower or a bed bath on those dates. During this period, the resident received a mix of bed baths and showers, but not consistently per the posted shower schedule, which indicated showers on Monday and Thursday evenings. Progress notes from 12/08/25 through 01/08/26 did not show that the resident refused showers or requested bed baths instead. On observation, the resident reported she had not had a shower for three weeks and had only been given bed baths, and stated she wanted showers and did not care about the time of day. When questioned, an LPN and a CNA stated the resident was scheduled for evening showers on days that were not their shift and suggested she might not be getting showers because she required a mechanical lift and two staff, and there might not have been enough staff available. The facility’s resident rights policy stated that residents have the right to make their own schedule, participate in care planning, and participate in decisions affecting their care.
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