Failure to Honor Resident Beverage Preference
Summary
The facility failed to honor Resident #22’s stated beverage preference by not consistently providing juice at meals and instead making water available. Resident #22 was admitted with diagnoses including dementia and chronic kidney disease, and the most recent MDS showed the resident was cognitively impaired and required supervision and assistance with eating and drinking, relying on staff to maintain adequate hydration. The facility’s Resident Centered Care Food Preferences document identified juice as the resident’s preferred beverage at meals, and there was no documentation that the resident preferred water over juice. During observations on multiple occasions, only water was available at the resident’s bedside or during meal periods, and no juice or other preferred beverage was observed. The resident’s daughter and POA stated the resident does not want water to drink and prefers juice, and expressed concern that the preference was not consistently honored. Staff interviews showed the LPN and CNAs were not aware of the resident’s preference for juice and reported they typically provided fluids available on the unit unless otherwise directed. The facility policy stated fluids are to be provided based on resident preferences.
Penalty
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Failure to provide scheduled bathing: A resident who was cognitively intact, dependent for all ADLs, and had multiple complex medical conditions did not receive bed baths twice weekly as scheduled. The resident reported missed bathing care, shower sheets showed multiple missed baths and two extended gaps without documentation, and the DON confirmed the resident did not refuse care and that there was no documentation supporting the missed baths.
Failure to provide bathing per resident choice: A resident with no cognitive impairment and substantial ADL needs was scheduled for showers three times weekly, but the bathing record showed repeated bed baths instead of showers. The resident said showers were not provided because of staffing shortages and that she sometimes refused bed baths because she wanted a shower. CNAs confirmed showers were missed due to lack of time and that bed baths were given instead, despite the resident's preference for showers.
Several residents expressed a desire to eat in the dining room, but the facility failed to provide a comfortable environment due to inadequate heating. Temperatures in the dining room and other common areas were consistently low, as the main boiler was non-functional and auxiliary heaters were insufficient. As a result, all meals were served in residents' rooms, and residents' choices regarding dining location were not supported.
Three residents with significant physical limitations and intact cognition did not consistently receive scheduled showers as required, with missing or incomplete documentation and reports from both residents and staff confirming missed care. Facility policy required documentation of showers or refusals, but this was not followed, resulting in a failure to support resident choice and self-determination.
A resident with ALS and dysphagia was kept on a pureed diet without supporting medical assessments, despite repeatedly expressing a desire to return to a regular diet. The facility did not offer alternative food options or document informed refusal, and staff confirmed that only pureed food was provided until further swallow studies were completed, failing to support the resident's right to self-determination.
A resident with multiple neurological diagnoses and a history of family conflict was transferred to another facility without documented evidence that she participated in or agreed to her discharge plan. Despite indications of intact cognition and requests for a court-appointed guardian, staff did not document any conversations with the resident about her involvement in the discharge process, resulting in a failure to support resident self-determination.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to ensure that Resident #46 was bathed according to his scheduled preference of twice weekly. Resident #46 was admitted with diagnoses including chronic respiratory failure, alveolar hypoventilation, morbid obesity, neurogenic bladder, hypertension, dependence on ventilator, COPD, asthma, type 2 diabetes mellitus, depression, and anxiety. The annual MDS assessment showed he was cognitively intact, had no behaviors or refusals of care, and was dependent for all ADLs and transfers, with bowel incontinence and a urinary catheter in place. The resident stated he did not receive bathing care twice a week as scheduled. Review of shower sheets showed missed bed baths on multiple dates, including 01/04/26, 01/14/26, 01/18/26, 02/08/26, and 02/22/26, as well as two separate two-week periods when no baths were documented. The DON confirmed the resident was scheduled for bathing on Wednesdays and Sundays, that he did not refuse bathing, and that there was no documentation supporting the missed bed baths. The DON also stated the facility standard was to offer bathing two times per week.
Failure to Provide Bathing per Resident Choice
Penalty
Summary
The facility failed to provide bathing per resident choice for one resident who had no cognitive impairment and required substantial to maximal assistance with ADLs. The resident was admitted with diagnoses including unspecified convulsions, dysphagia, epilepsy, hyperlipidemia, hypothyroidism, GERD, anxiety, and asthma. The care plan directed that the resident receive showers every Monday, Wednesday, and Friday on second shift with staff assistance, and the bathing record showed that on multiple occasions the resident received a bed bath instead of the preferred shower. The bathing record also showed that on two dates the resident refused a bed bath. The resident stated that staff did not provide showers because there were not enough staff in the building and that showers became bed baths. The resident said she sometimes refused the bed bath because she wanted a shower instead. A CNA confirmed she was unable to provide the resident a shower because she did not have time and instead gave a bed bath. Another CNA stated there were few instances when showers were not given due to lack of time and that when a shower could not be provided, she would give the best bed bath she could. The facility's Resident Rights Policy stated that the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Failure to Accommodate Resident Dining Preferences Due to Inadequate Heating
Penalty
Summary
The facility failed to accommodate residents' preferences to eat in the dining room due to inadequate heating in common areas, including the dining room itself. Observations revealed that the temperatures in these areas, measured by the Maintenance Director using a hand-held infrared thermometer, ranged from 51.2 to 56.5 degrees Fahrenheit. The boiler responsible for heating these spaces was found to be non-functional and had been permanently shut off, with exposed wires visible in the boiler room. Auxiliary heaters were present but insufficient to make the dining room comfortable for regular use. Staff interviews confirmed that the dining room had not been used for meals or activities for two years, except for a single event where additional heaters were used. Resident interviews indicated a clear desire to eat in the dining room if the temperature were comfortable. One resident, who was cognitively intact and independent with eating, specifically expressed enjoyment in dining in the communal space but cited the cold as a deterrent. Other residents echoed this sentiment. The Administrator acknowledged that the dining room and other common areas had not been prioritized for heating due to cost concerns and stated that the focus was on maintaining resident room temperatures. As a result, all meals were served in residents' rooms, and the facility did not support or facilitate resident choice regarding dining location.
Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for bathing received showers on their scheduled days according to their preferences. Medical record reviews, resident and staff interviews, and documentation audits revealed that three residents with intact cognition and significant physical limitations did not consistently receive scheduled showers. For example, one resident with multiple sclerosis, COPD, and atrial fibrillation, who required maximal assistance and mechanical lift transfers, had no shower documentation for two consecutive months and confirmed missed showers. Another resident with a right lower leg fracture and bipolar disorder, requiring moderate assistance, did not receive a scheduled shower, with no documentation or record of refusal, and also reported missed showers. A third resident, with a left femur fracture and polyneuropathy, dependent on a wheelchair and requiring substantial assistance, did not receive a scheduled shower, and documentation was incomplete. This resident stated that she had not received a shower for over a week and described waiting for staff assistance that never occurred. Staff interviews confirmed inconsistencies in documentation and communication regarding shower schedules, with some confusion between day and night shift responsibilities. The Director of Nursing verified the absence of required documentation for the affected residents on the specified dates. Facility policy required staff to document when showers were performed or refused, including the reason for refusal, but this was not consistently followed. The lack of documentation and missed showers for residents dependent on staff for bathing constituted a failure to honor resident choice and self-determination, as well as a failure to follow established care plans and facility procedures.
Failure to Honor Resident Choice in Diet Texture
Penalty
Summary
A resident with multiple complex medical diagnoses, including ALS, dysphagia, and recent dental procedures, was admitted to the facility and subsequently placed on a pureed texture diet. The hospital discharge summary recommended a soft diet for an unspecified number of days following a dental procedure, but did not indicate a need for a long-term downgrade in diet texture. Despite this, the facility maintained a pureed diet order for the resident without documentation of appropriate medical tests or assessments, such as a modified barium swallow study, to justify the continued restriction. The resident, who was cognitively intact, repeatedly expressed dissatisfaction with the pureed diet and requested to revert to a regular texture diet, but there was no evidence that the facility offered this option or documented informed refusal with acknowledgment of risks. Interviews with the resident confirmed that he refused facility meals due to the pureed diet and had to purchase his own food, as no alternatives were provided. Staff interviews, including those with the dietitian, SLP, and LPN, confirmed that the resident was only offered pureed food and that changes to the diet order were contingent on further swallow studies, which had not been completed. The facility failed to honor the resident's right to self-determination and choice regarding diet texture, as required, by not facilitating or documenting the resident's informed choice to assume risk and select a different diet texture.
Failure to Ensure Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was provided with choice and self-determination regarding discharge planning. The resident, who had diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage, aphasia, dysphagia, and memory deficit, was admitted with three daughters named as healthcare POAs. Despite a Brief Interview of Mental Status (BIMS) score indicating intact cognition, a physician letter later stated the resident had cognitive impairment and required assistance with decision making, also mentioning possible financial abuse. Progress notes documented the resident's attempts to change POA paperwork, her request for facility representation during family visits, and her expressed desire for a court-appointed guardian. The resident also stated she did not want two of her daughters involved, citing family conflict. Facility staff reported they would follow POA paperwork and the resident's wishes, but interviews with the DON and Social Services confirmed there was no documented evidence that the resident participated in or agreed to her discharge plan. The timing of the physician letter and the family's request for transfer was noted as suspicious, especially as it followed the resident's request for a court-appointed guardian. Social Services acknowledged that no conversations with the resident regarding her involvement in the discharge process or her agreement to the plan were documented, resulting in a failure to honor the resident's right to self-determination in discharge planning.
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