Failure to Update DNR Status Leads to Unnecessary CPR
Summary
The facility failed to ensure that new physician's orders were obtained for a resident with a legal guardianship that included a Do Not Resuscitate (DNR) directive. The resident, who had Alzheimer's Disease and depression, was admitted to the facility with a full code status. However, the guardianship was updated to include a DNR directive, which was not reflected in the resident's Medical Order for Life Sustaining Treatment (MOLST) form. As a result, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) based on the blank MOLST form, which indicated a full code status. The incident occurred when a nurse, unfamiliar with the resident, was alerted by a Certified Nurse Aide that the resident was unresponsive. The nurse found a blank MOLST form in the resident's medical record and initiated CPR, believing that a blank form required resuscitation efforts. The Assistant Director of Nurses and the former Director of Nurses assisted with CPR until emergency medical services arrived, but the efforts were unsuccessful, and the resident was pronounced dead. Interviews with facility staff revealed that the updated guardianship, which included the DNR directive, had not been received by the facility due to multiple staffing changes, particularly in the Social Services Department. The Director of Clinical Operations confirmed that the facility never received the expanded guardianship documentation, which would have prompted a change in the resident's code status to DNR. This oversight led to the initiation of CPR against the resident's updated advanced directive.
Penalty
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A resident with moderate unspecified dementia and Sjogren syndrome with keratoconjunctivitis complained that the room lights were too white, bright, and harsh and asked for softer, more yellow lighting. Staff repeatedly responded by turning the lights off, but no work order was submitted to maintenance for the requested lighting change, despite staff stating that lighting concerns should be forwarded to maintenance.
A resident with intact cognition and diagnoses including anxiety and stroke-related hemiparesis/hemiplegia was prevented by a CNA from leaving the dining room when the CNA stood in front of the wheelchair and placed both hands on the armrests while telling the resident to stay because they were being monitored for falls. The resident and family later reported the resident was hit or pushed during the interaction, police responded, and the resident was transferred to the hospital for chest pain. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment.
Routine wound care was scheduled around staff convenience instead of resident preference. Surveyors found two wound nurses routinely starting as early as 2:30 AM to complete non-emergent dressing changes, with no MD order requiring overnight treatment, no documented sleep-preference assessments, and no resident consent for middle-of-the-night care. Interviews with the DON, administrator, medical director, and wound nurses confirmed the early schedule had been used for years to accommodate workload and staff schedules, and several residents or representatives reported being awakened overnight for wound care.
A resident with intact cognition, anxiety, depression, impaired balance, limited mobility, and limited ROM requested two baths per week, but the facility did not follow that preference. Although the care plan and physician order both indicated two baths weekly, the bath schedule showed only one bath assigned, and staff confirmed the schedule did not match the order.
A resident with cognitive impairment, dysphasia, and malnutrition-related diagnoses was repeatedly served breakfast trays that did not match the meal ticket or the resident’s documented food preferences. Staff observed scrambled eggs being provided instead of the ordered/preferred egg preparation, and the resident stated she did not like eggs and had previously requested not to receive them. Interviews with NA, RN, RD, DON, and culinary leadership confirmed that resident choices should be honored and that meals should match the ticket.
Failure to provide or offer routine showers: A resident with hemiplegia, anxiety, and MDD was dependent on staff for bathing and said he/she went more than two weeks without a shower and wanted more showers. The record showed gaps in shower documentation, including a 15-day period with no documented shower provided or offered, while CNA and LPN interviews confirmed residents were generally to receive showers twice weekly and refusals should be documented.
Failure to Honor Resident Request for Different Room Lighting
Penalty
Summary
The facility failed to honor a resident’s request for different room lighting and did not facilitate the resident’s stated preference for softer, more yellow light. The resident had a quarterly MDS indicating a diagnosis of moderate unspecified dementia, and the care plan identified Sjogren syndrome with keratoconjunctivitis, a condition that can cause pain, impaired eyesight, and light sensitivity. During observation and interview, the resident was cognitively alert and able to answer questions appropriately, and stated she really hated the lights in her room because they were too white, bright, and harsh. She identified the circular overhead light between the two resident spaces and the rectangular wall light above her bed as the most bothersome. When the resident complained, a NA responded by turning the lights off, and the resident stated that staff always did that whenever she complained. RN-B stated she would normally complete a work order for lighting complaints but had not done so for this resident, and she said she usually responded by turning off the lights. The DOM stated nursing staff were expected to send a maintenance request for room lighting concerns and that he could change bulbs if lights were too bright, but he had not received any recent requests for different lighting or bulbs. RN-A also stated staff were expected to submit a work order if a resident wanted a different type of light, and she was not aware of the resident’s request. The DON stated nursing staff were expected to contact maintenance if a resident complained about lighting or requested a different type of lighting, and a policy regarding resident choices was requested but not received.
Resident Prevented From Leaving Dining Room
Penalty
Summary
The facility failed to ensure that a resident was able to exercise autonomy regarding choices important to their life. On 02/15/2026 at about 5:00 PM, Resident #1, who was alert and oriented times three and had intact cognition on the Minimum Data Set dated 02/04/2026, attempted to leave the dining room in a wheelchair. Certified Nursing Assistant #1 stood in front of the wheelchair and placed both hands on the armrests, preventing the resident from leaving the dining room while explaining that the resident should remain there because they were being monitored and were at risk of falling. Resident #1 was admitted with diagnoses including anxiety and cerebral infarction with hemiparesis and hemiplegia. The care plan documented that the resident was able to make leisure preferences known, including watching television, reading, and listening to music. During the interaction, Certified Nursing Assistant #1 stated the resident refused to return to the dining room, and the CNA positioned themself in front of the wheelchair and pushed the chair back while keeping hands on the armrests. The CNA reported that the resident then hit and kicked them in the chest area, and the CNA stated they were trying to keep the resident in the dining room until the resident's family came. The investigation record also included reports from the resident's family that the resident said they were hit on the right chest and right knee by the CNA. A nursing note documented that police responded and the resident was transferred to the hospital for chest pain. Later interviews reflected that the resident reported being pushed back into the wheelchair very hard when asking to be put back in bed because sitting in the chair hurt their hips and legs. The facility's investigation concluded there was no evidence of abuse, neglect, or mistreatment, while the Assistant DON stated staff were trained on resident rights and that residents have the right to move about freely.
Routine wound care scheduled around staff availability rather than resident preference
Penalty
Summary
The facility failed to establish care schedules based on individual resident preferences and needs, instead allowing routine wound care to be performed during overnight hours to accommodate staff schedules. Surveyors reviewed timecard records showing two dedicated wound nurses routinely starting as early as 2:30 AM and 3:30 AM to complete non-emergent wound treatments while residents were sleeping. The record review found no physician orders requiring middle-of-the-night wound care, no documented assessments of resident sleep preferences or overnight routines, and no documented resident consent for routine care between 2:30 AM and 4:00 AM. The deficiency affected 5 sampled residents and was described as a broader practice affecting 83 residents with active wound care orders. The facility census roster showed 90 current residents, with 83 having active physician orders for wound care management. Treatment Administration Records for the sampled residents showed nurse initials documenting wound care completion, but the TARs did not include specific timestamps to verify when the care was actually provided. Facility leadership acknowledged that the wound nurses typically punched in between 3:00 AM and 3:30 AM to conduct wound treatments and that the schedule had been in place for years to accommodate staff needs. Resident-specific interviews and record reviews showed that the practice occurred without individualized consent or preference assessment. One resident had severe cognitive impairment and multiple active wounds, and the resident’s representative stated she had never been asked about early morning wound care and would not have agreed to it. Other cognitively intact residents reported being awakened in the middle of the night for dressing changes, with one resident’s sister-in-law reporting that he was startled awake and unable to sleep due to the disruption. Another resident stated staff woke her around 3:00 AM or 3:30 AM and that she was never asked for permission, while a different resident reported being awakened around 2:00 AM or 3:00 AM and feeling sleepy afterward. Interviews with administrators, the DON, the VP of Clinical Operations, the Director of Culture and Engagement, the Medical Director, and the wound nurses confirmed that the early schedule was driven by workload and staff availability rather than resident preference or a physician-directed overnight need.
Bathing Schedule Did Not Follow Resident Choice or Physician Order
Penalty
Summary
The facility failed to follow a resident’s bathing choice and physician-ordered bathing frequency for one resident who had intact cognition, anxiety disorder, depression, impaired balance, limited mobility, and limited range of motion. The resident stated she had requested two baths per week since admission, but that request was not fulfilled, and she later asked her physician to write an order for two baths per week because she felt uncomfortable and unclean when she was not able to shower twice weekly. The resident’s care plan was updated to include two baths per week and as needed, and her physician entered an order for two baths weekly. However, the hallway bath schedule showed only one bath scheduled for the week, with no second bath day listed. Staff confirmed that the bath schedule was expected to follow physician orders, but the resident remained scheduled for only one bath on Mondays despite the order for two baths per week. Medical records staff stated she updated the bath schedule based on physician orders, but was not aware of this resident’s order until it was found later.
Failure to Honor Resident Food Preferences and Meal Ticket Orders
Penalty
Summary
The facility failed to honor a resident’s right to make choices about food preferences at meals. The resident had moderate cognitive impairment and diagnoses including type 2 diabetes, acute cystitis, muscle weakness, history of transient ischemic attack and cerebral infarction, dysphasia, and protein-calorie malnutrition. The care plan and nutrition assessment both directed staff to cater to food preferences as much as possible, and the resident’s documented preferences included pureed eggs, while the nutrition assessment also noted no eggs. The resident’s meal ticket reflected specific texture and preference instructions, including a pureed egg option. During multiple meal observations, the resident was served breakfast trays that did not match the meal ticket and included scrambled eggs instead of the ordered texture or preferred preparation. On one occasion, the resident ate only a bite or two of the scrambled eggs, and a nursing assistant confirmed the tray did not match the ticket. On another occasion, the resident stated she did not really like eggs and had previously requested not to have them, but reported that lately she seemed to get scrambled eggs for breakfast. During that meal, the nursing assistant fed spoonfuls of food without offering sips of beverage in between, then gave the resident a spoonful of scrambled egg; the resident chewed it for approximately five minutes with several attempts at swallowing before declining more food. Staff interviews confirmed that meals were expected to match the meal ticket and that resident choices should be honored, while facility policy required verification of meal accuracy and offering alternatives for refused foods or dislikes.
Failure to Provide or Offer Routine Showers
Penalty
Summary
The facility failed to protect the resident's right to self-determination when staff did not ensure the resident received, or was offered, showers on a routine basis according to the resident's reasonable preference. The resident had hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side, anxiety disorder, and major depressive disorder. The quarterly MDS showed the resident was cognitively intact and dependent on staff for showers, bathing, personal hygiene, and shower/bathing transfers. The care plan directed staff to assist with daily care, encourage the resident to do what was within physical ability, provide bathing per schedule, and noted the resident refused bathing/showers and may take bed baths. The resident told the surveyor he/she went over two weeks without a shower earlier in July 2026 and wanted more showers, stating staff said he/she refused showers but they just did not want to give them. The CNA shower review and bathing task documentation showed showers on some dates and a refusal on one date, but the nurses' notes did not document showers given or refused from 07/02/26 through 07/18/26, and the record did not show a shower provided or offered during that 15-day period. Staff interviews indicated residents were generally supposed to receive showers two times a week, refusals should be documented, and another shower should be offered later if a resident refused.
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