Adira Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 3200 State Street, Saginaw, Michigan 48602
- CMS Provider Number
- 235250
- Inspections on file
- 33
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Adira Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with significant comorbidities developed three facility-acquired pressure ulcers, including a Stage 3 coccyx ulcer, an unstageable left heel wound, and a deep tissue injury to the left lateral malleolus. Facility staff inconsistently classified and documented these wounds, reclassifying them multiple times despite diagnostic imaging showing no vascular insufficiency. The resident was not consistently provided with off-loading devices, and daily skin inspections and timely interventions were not reliably documented, contributing to the development and progression of the wounds.
The facility did not provide staff with effective call light notifications or ensure timely responses to resident requests. Staff relied on a screen at the nurse's station, which was not visible from key areas, and walkie talkies were inconsistently used. As a result, a resident experienced repeated delays in assistance, leading to multiple falls while attempting to self-transfer to the bathroom.
The facility failed to implement and document appropriate interventions for two residents with skin breakdown and pressure ulcers, including lack of wound assessments, missing or incorrect wound treatments, and inaccurate documentation of care. Additionally, a resident with a testicular infection did not receive adequate follow-up assessment or monitoring after antibiotic treatment, with no evidence of resolution documented in the medical record.
A resident with severe cognitive impairment and multiple health conditions experienced several unwitnessed falls, some with head injuries and skin tears. Facility staff did not consistently perform or document required neurological checks after these incidents, and nursing progress notes were incomplete or missing. Policies requiring individualized interventions and care plan updates were not followed, as confirmed by the DON.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required, with staffing records showing multiple days with insufficient or missing RN coverage. The Administrator and DON were unable to account for these lapses during review.
The facility failed to prevent and manage pressure ulcers for several residents, leading to the development and worsening of pressure injuries. A resident with a stage three ulcer did not receive consistent care due to staffing issues, while another resident with a sore on their buttocks reported pain and inadequate repositioning. A third resident, with limited mobility, developed pressure injuries due to improper positioning and lack of staff assistance. Observations and staff interviews highlighted a lack of adherence to care plans and missed wound treatments.
The facility failed to provide dignified and professional care to residents, resulting in extended wait times for assistance, incontinence, and feelings of frustration. Residents reported discourteous staff, delayed call light responses, and inappropriate staff behavior. Specific incidents included residents being told to use their briefs due to staff unavailability, being left uncovered, and staff using cell phones during care. The facility's administrator acknowledged these concerns, indicating awareness of the deficiencies.
The facility failed to provide routine showers and hygiene care for multiple residents, leading to feelings of embarrassment and frustration. Several residents reported not receiving showers for weeks, and observations revealed poor hygienic conditions. The facility's documentation was inconsistent, and staff shortages contributed to the inadequate care.
The facility failed to properly label and store medications, with multiple medication and treatment carts containing undated and unsecured items. Observations revealed unlocked treatment carts accessible to residents and loose medication tablets in drawers. Additionally, temperature logs for medication refrigerators were incomplete or showed temperatures outside the recommended range, risking medication efficacy and safety.
The facility failed to maintain a comprehensive infection control program, with missing documentation and inadequate surveillance. Observations revealed improper disposal of soiled items and lapses in hand hygiene, increasing infection risks. Additionally, medication administration and dressing change procedures were not compliant with infection control protocols, further compromising resident safety.
The facility failed to complete advance directives for seven residents, resulting in missing or incomplete forms. Despite having physician's orders for CPR or full code by default, no signed documents indicating code status were found in the EMR. Interviews with social workers revealed that forms were supposed to be signed and uploaded, but they were unable to locate them. The facility's policy requires providing residents with information about their rights to refuse or accept treatment and to formulate advance directives, but this was not adhered to.
The facility failed to review and revise care plans for several residents, leading to unmet care needs such as missed showers, inadequate catheter care, and significant weight loss. One resident reported missing scheduled showers and inconsistent catheter care, while another experienced a notable weight loss without appropriate care plan adjustments. Additional residents faced issues with bathing due to inadequate equipment and insufficient assistance, highlighting a lack of adherence to facility policies on care plans and bathing guidelines.
A facility failed to conduct timely activity assessments for residents and did not support a resident's voting rights. The Activities Director was unaware of the requirement for quarterly assessments, leading to incomplete documentation for several residents. Additionally, a resident expressed a desire to vote, but there was no follow-up to facilitate this, contrary to the facility's policy.
The facility failed to administer medications, particularly insulin, in a timely manner, affecting multiple residents with diabetes. Staffing issues and lack of coordination led to significant delays, with medications often given hours late. Additionally, the facility did not utilize backup medication sources, resulting in residents missing doses of essential medications.
The facility failed to provide adequate catheter care and infection prevention for several residents, leading to potential and actual urinary tract infections. Residents reported irregular catheter changes and inadequate care, with observations confirming catheter bags and tubing in contact with the floor. Facility records showed gaps in documentation and compliance with physician orders, highlighting systemic issues in catheter care.
The facility failed to consistently offer nighttime snacks to residents, leading to frustration and unmet needs. Observations and interviews revealed that residents were not consistently offered snacks, with some going long periods without them. A diabetic resident expressed concern about not receiving snacks necessary for managing low blood sugar. The facility's policy did not specify responsibility for snack provision, and documentation showed inconsistencies in offering snacks. The meal schedule indicated a 14-hour gap between dinner and breakfast without consistent snack offerings.
The facility failed to maintain an effective Antibiotic Stewardship Program, leading to potential inappropriate antibiotic use among residents. Incomplete documentation and discrepancies in infection reporting were noted, with some residents receiving multiple antibiotics without proper justification. A resident was prescribed Doxycycline for a wound infection without supporting documentation, highlighting the facility's oversight issues.
A resident, who is cognitively intact, was moved from the rehab section to the LTC section without their consent, despite expressing unhappiness and not planning to stay long-term. The facility's policy allows residents to refuse such changes, but the reason for the move was marked as 'other' in the EMR. The social worker did not initially recall the resident's distress, but later documentation confirmed their dissatisfaction.
The facility failed to provide adequate notice of non-coverage and maintain documentation for two residents, leading to a lack of full disclosure related to Medicare rights and the inability to appeal discharges within the allotted time frame. One resident's form was signed on the same day services ended, while the other resident's form could not be found. The facility Administrator acknowledged the missing form and stated that forms should be provided 48 hours prior to discharge.
A resident was found in a customized chair with a chest harness that they could not remove independently, without proper assessment or monitoring. The facility lacked a current physician order for the harness and had no physical restraint policy. Staff confirmed the resident's inability to release the harness, and the MDS assessment inaccurately coded the resident as not using restraints.
The facility failed to obtain timely weights for two residents, leading to unassessed weight loss. One resident lost 17.1 pounds in 16 days, while another had issues with enteral feeding administration, with an empty bottle left unattended. Care plans were outdated, and the Corporate RD did not see the need for re-weighing despite evident weight issues.
A facility failed to ensure accurate enteral feeding orders for a resident, resulting in an incomplete order and potential for tube malfunction or weight loss. Observations revealed the resident's feeding pump was beeping due to an empty bottle, and the new bottle was not labeled. The RN noted that the night shift did not hang the full bottle, causing the feeding to run longer than intended. The order lacked documentation for hang and take-down times, deviating from physician's orders.
A facility failed to ensure effective communication and coordination for a resident requiring dialysis, resulting in duplicate influenza vaccinations. The resident, with severe cognitive impairment and multiple diagnoses, had a care plan for dialysis but lacked completed communication forms in their medical record. The facility's infection control manager confirmed the duplication and noted the absence of vaccination records in the Michigan Care Improvement Registry, highlighting a breakdown in communication with the dialysis center.
The facility failed to conduct timely medication regimen reviews for three residents, resulting in missed reviews and delayed responses to pharmacy recommendations. A resident with cerebral palsy missed a review in July, while another with moderate cognitive impairment had a delayed response to a dose reduction recommendation. A third resident with dementia had recommendations unaddressed until questioned. The facility lacked clear timeframes for responding to pharmacy recommendations.
The facility failed to ensure adequate indications and monitoring for psychotropic medications for three residents. A resident was prescribed Zolpidem without a sleep disorder diagnosis, and staff could not provide documentation for its necessity. Another resident was on Ramelteon for insomnia without a care plan or monitoring, and a third resident continued Risperdal without documented behaviors justifying its use. The facility's actions resulted in a lack of documented evidence supporting the effectiveness and necessity of these medications.
The facility failed to prevent pre-set up medications in medication carts, did not prime a new insulin pen before administration, and provided late insulin administration for a resident. An RN found pre-set up medications in unmarked cups, and an LPN administered insulin without priming the pen. A resident reported receiving insulin late, confirmed by records showing multiple late administrations, with staffing issues contributing to the delay.
A resident with cerebral palsy and other conditions did not receive routine dental services since admission to the facility. Despite being cognitively intact and having a signed dental consent form, the sections for consenting to or declining dental care were left blank. Interviews with staff confirmed the resident had not been seen by a dentist, contrary to the facility's policy on providing dental services.
The facility failed to follow its vaccination administration procedures, affecting three residents. One resident did not receive the Pneumonia vaccine despite it being ordered, another had discrepancies in vaccine documentation, and a third did not receive the Pneumonia vaccine with no documented reason. The facility's policy requires proper documentation and administration of vaccines, which was not adhered to.
The facility failed to prevent non-consensual sexual behaviors between two cognitively-impaired residents in the Dementia Unit. A female resident with bipolar disorder and dementia was found partially naked in bed with a male resident with Alzheimer's disease. The incident was not reported or investigated in a timely manner, and the facility's documentation was incomplete. The deficiency was due to inadequate supervision and failure to implement abuse prohibition policies.
A resident with severe cognitive impairment was not honored for her DNR wishes due to the facility's failure to complete necessary documentation. Despite having a designated patient advocate, the facility treated the resident as a Full Code because the Incapacity to Make Health Care Decisions Form was incomplete. This resulted in the resident receiving unwanted CPR and subsequently dying.
A resident with a medical history requiring IV antibiotics left the facility and was missing for over 24 hours. The facility failed to report the incident to local authorities or the state agency, as required by their policy. The Administrator and DON were unaware of the resident's absence until the following day, and no investigation was conducted to determine if the case was reportable.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with frequent Leaves of Absence. The first resident's Advanced Directive was not addressed, resulting in a voided DNR order and the resident receiving CPR. The second resident's care plan did not include interventions for frequent absences, and the facility did not report the resident missing when they failed to return. Facility policies on Advanced Directives and care planning were not followed.
A resident with severe cognitive impairment was subjected to CPR against their DNR wishes due to the facility's failure to process the necessary incapacity documentation in a timely manner. The resident's family, including the designated patient advocate, was not informed of the resident's declining condition and witnessed the CPR, which was contrary to the resident's documented DNR order.
Failure to Prevent and Accurately Classify Facility-Acquired Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including diabetes, dementia, kidney disease, and heart disease, was admitted to the facility with no skin issues. Over the course of their stay, the resident developed three facility-acquired pressure ulcers: a Stage 3 ulcer on the coccyx, an unstageable wound on the left heel, and a deep tissue injury on the left lateral malleolus. The resident was non-ambulatory, required assistance for all activities of daily living, and was incontinent of bowel and bladder, with infrequent changes and prolonged periods between incontinence care. Facility staff, including CNAs and wound care nurses, observed and documented the wounds at various stages, but there were inconsistencies in the classification and documentation of the wounds. The wounds were initially identified as pressure injuries but were later reclassified multiple times as either moisture-associated skin damage (MASD) or diabetic/vascular ulcers, despite diagnostic imaging (doppler studies) showing no evidence of vascular insufficiency. The facility's wound care team and DON provided conflicting explanations for the reclassification, and there was a lack of clear, consistent documentation regarding the nature and progression of the wounds. Observations revealed that the resident was not consistently provided with off-loading devices, such as heel boots, and was often found with heels resting directly on the bed. Daily skin inspections and timely interventions, as outlined in the facility's own skin management policy, were not consistently documented or observed. Additionally, a new skin alteration was noted without corresponding documentation. These actions and inactions contributed to the development and worsening of the resident's pressure ulcers, as well as inconsistencies in wound assessment and care.
Failure to Ensure Timely Call Light Response and Notification
Penalty
Summary
The facility failed to ensure that call light notifications were readily available to staff and that call lights were responded to in a timely manner to meet residents' needs. Observations revealed that the call light system relied on a screen located at the nurse's station, which was not visible from the hallways or dining areas where staff were often present. There were no visual or audible indicators in the hallways to alert staff when a call light was activated, and staff had to physically walk to the nurse's station to check the status of call lights. Although staff were assigned walkie talkies, these were not consistently used or audible, and some staff admitted to leaving them at the nursing station or turning the volume down. Multiple interviews and observations indicated that residents experienced significant delays in receiving assistance after activating their call lights. One resident reported waiting 20-30 minutes or more for help, and described instances where staff did not return after being asked for assistance. This resident had several documented incidents of attempting to go to the bathroom unassisted, resulting in falls, which he attributed to the lack of timely response to his call light requests. During surveyor observations, call lights were activated without any corresponding noise or alert in the hallway, and staff did not respond promptly. The facility's policy required prompt response to call lights and for staff to be aware of call light activations, but the current system and staff practices did not support this. Interviews with the administrator and DON confirmed that there were no hall lights or alarms to notify staff of call light activations, and that this was an area under consideration for improvement. The lack of effective notification and response systems directly contributed to unmet resident needs and repeated incidents of residents attempting to self-transfer, leading to falls.
Failure to Provide Appropriate Skin and Wound Care Interventions and Monitor Change in Condition
Penalty
Summary
The facility failed to provide appropriate interventions and care for residents experiencing skin breakdown and pressure ulcers, as well as for a resident with a change in condition. For one resident with a history of incontinence and previous pressure ulcers, a large, excoriated area was observed on the buttocks. Despite care plans indicating the need for daily wound assessments and treatments, there was no documentation of daily assessments or any treatment orders for the skin breakdown. The wound nurse confirmed the presence of a wound but stated the resident was not on his list to be seen, and the medical record did not reflect any wound care interventions or accurate skin assessments. Another resident with an unstageable pressure ulcer on the left lateral ankle did not receive the prescribed wound care. The dressing observed did not match the physician's order, lacking the required calcium alginate. Documentation on the treatment administration record indicated the dressing change was completed, but the nurse later admitted she had not performed the dressing change and had signed off for the wound nurse. The wound was noted to have significant drainage and was not improving, with the wound nurse and hospice nurse confirming it was facility-acquired. Additionally, a resident with a history of dementia and multiple comorbidities developed a large, red, inflamed testicle. Although antibiotics were prescribed, there was no documentation of follow-up assessments to determine if the infection had resolved. The care plan referenced impaired skin integrity and called for treatments as ordered and weekly skin assessments, but there was no evidence of ongoing monitoring or documentation regarding the resolution of the infection. The lack of assessment and monitoring was confirmed during interviews with nursing staff, who were unable to provide evidence that the resident's condition had been evaluated after the initial treatment.
Failure to Prevent Repeat Falls and Inconsistent Neurological Monitoring
Penalty
Summary
The facility failed to prevent repeat falls and provide consistent neurological monitoring for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, debility, and malnutrition. The resident experienced several unwitnessed falls, some resulting in head injuries and skin tears. Despite the facility's policy requiring individualized interventions and neurological assessments after unwitnessed falls or head injuries, documentation revealed that neurological checks were not completed or recorded following multiple incidents. Additionally, nursing progress notes and interdisciplinary team documentation were inconsistent or missing regarding the resident's falls and injuries. The facility's policies also required that changes in a resident's condition, such as falls with injury, be documented and prompt a review or revision of the care plan. However, after several falls, there was a lack of timely and thorough documentation in the resident's medical record, and interventions were not consistently updated or implemented as required. The DON confirmed that neurological monitoring should have occurred after each unwitnessed fall, but records showed this was not done, indicating a failure to follow established protocols for fall prevention and post-fall assessment.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours each day, seven days a week, as required. Review of the posted nurse staffing sheets for the period from January 1, 2025, to March 6, 2025, revealed several days where there was either no RN coverage or less than the required eight hours of RN coverage. Specifically, on multiple days in January and February 2025, the staffing sheets showed either zero RN hours, fewer than eight RN hours, or were left blank except for census and date. During a review with the Administrator and Director of Nursing, it was confirmed that there were days without the required RN coverage, and both were unable to explain the discrepancies.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management, affecting multiple residents. Resident #56 was found with a stage three pressure ulcer on their back, which was not consistently treated due to staffing issues. The resident reported that staff did not assist with turning and repositioning every two hours as required. Observations confirmed that the resident was often left lying on their back with heels against the mattress, contrary to care plan interventions. Resident #60, who was at risk for pressure ulcers, was observed with a sore on their buttocks and reported pain. The resident's care plan included interventions for turning and repositioning, but these were not consistently implemented. The resident was often found lying on their back without positioning devices, and staff were unaware of the resident's wound care needs. The facility's records indicated missed wound treatments and a lack of alternative methods to offload pressure. Resident #76, with a history of stroke and limited mobility, was observed lying on their back with feet pressed against the footboard, indicating a lack of proper positioning. The resident reported that staff did not assist with repositioning, and observations confirmed the absence of heel suspension devices. The resident developed pressure injuries on their foot and heel, which were not addressed in a timely manner. Staff interviews revealed a lack of awareness and adherence to the resident's care plan, contributing to the development of pressure ulcers.
Deficiencies in Resident Care and Staff Responsiveness
Penalty
Summary
The facility failed to provide dignified, respectful, and professional care to 12 residents, resulting in extended wait times for assistance, incontinence, and feelings of frustration and sadness among residents. Residents reported that staff were discourteous, did not respond to call lights in a timely manner, and often left them feeling like a burden. Specific incidents included a resident who had to call the facility on their phone to get help, another who was told to use their brief because staff did not have time to assist them to the bathroom, and a resident who was left uncovered and exposed in their room. Several residents reported that staff had poor attitudes, were rude, and used inappropriate language. One resident mentioned that staff told them it was easier to change their brief than to assist them to the toilet, while another resident was left with visible facial hair that staff had not offered to help remove. Additionally, residents expressed concerns about staff using their cell phones while providing care and being loud during shift changes, disrupting their sleep. The facility's failure to respond to call lights in a timely manner was a recurring issue, with residents reporting wait times of up to two hours. This lack of responsiveness led to incidents of incontinence and residents feeling neglected. The facility's administrator acknowledged the concerns and admitted that the facility had work to do, indicating awareness of the deficiencies in care and treatment provided to the residents.
Inadequate Hygiene Care for Residents
Penalty
Summary
The facility failed to document and provide routine showers and hygiene care for 12 residents, resulting in feelings of embarrassment and frustration among the residents. During a confidential Resident Council meeting, seven residents reported not consistently receiving their showers, with some not having had a shower in two weeks. The residents expressed frustration and felt disregarded by the facility staff. Several residents were observed in poor hygienic conditions. Resident #57, who has diagnoses including Bipolar Disorder and Major Depression, received only one shower in the last 30 days. Resident #72, with diagnoses such as Dementia and Schizoaffective Disorder, received only two showers in the same period. Resident #56, who requires a Hoyer lift for transfers, was found in a room with a foul odor and had only received one shower a week, despite needing more frequent assistance. The resident expressed reluctance to ask for more showers due to staff being busy. Other residents, such as Resident #76, who has left-sided hemiplegia, reported receiving bed baths instead of showers due to staff shortages and difficulty in transferring. This resident also had unkempt fingernails and toenails, indicating a lack of routine care. Resident #24, who is cognitively intact, reported that staff often skipped her showers, and Resident #50, with moderate cognitive impairment, confirmed receiving only four showers in the last 30 days. The facility's failure to provide adequate hygiene care was consistent across multiple residents, as evidenced by the lack of documentation and the residents' testimonies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed in multiple medication and treatment carts. Specifically, medications such as insulin pens, inhalers, and nasal sprays were found opened and used without proper dating on the packaging. Additionally, loose medication tablets were discovered in the drawers of medication carts, indicating a lack of proper organization and potential for medication errors. These observations were made across various units, including the short hall Coast unit, long hall Coast unit, and the secure dementia unit. Furthermore, the facility did not adequately secure or lock treatment carts containing prescription creams and ointments. Observations revealed that treatment carts were left unlocked in areas accessible to residents, including those who were self-ambulating. This oversight was noted in both the Bay treatment cart and the dementia unit treatment cart, where multiple prescription creams and ointments were found opened and undated, posing a risk of unauthorized access and potential misuse. The facility also failed to maintain accurate temperature logs for medication refrigerators, with missing entries and recorded temperatures outside the recommended range. This was particularly evident in the Harbor/Coast unit and Bay units, where multiple shifts had undocumented or low temperatures. The improper temperature control could compromise the efficacy and safety of stored medications, including vaccines and insulin pens. Interviews with staff revealed a lack of awareness and monitoring regarding these temperature discrepancies.
Inadequate Infection Control and Documentation in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by missing documentation and inadequate surveillance. The Infection Control (IC) Registered Nurse (RN) was unable to provide complete line listing documentation for several months, including January, February, May, and September 2024. This lack of documentation hindered the facility's ability to track and monitor infections accurately. Additionally, the IC RN admitted to not tracking potential infections that did not require antimicrobial treatment, further compromising the facility's infection control efforts. Observations revealed significant lapses in infection control practices, including improper disposal of soiled linens and waste products. On the locked dementia unit, soiled items were left in open garbage bags on the floor, and staff were observed not performing hand hygiene after handling contaminated items. These practices increased the risk of microorganism transmission among residents. Furthermore, the IC RN acknowledged awareness of these issues but failed to take corrective action, indicating a lack of effective process surveillance and staff education. Additional deficiencies were noted in medication administration and dressing change procedures. An LPN was observed not performing hand hygiene before and after medication administration, and medication cups were found without proper identification. During a dressing change, another LPN used non-sterile scissors from their pocket, risking cross-contamination. These actions demonstrate a broader issue of non-compliance with infection control protocols, contributing to the facility's failure to maintain a safe environment for residents.
Failure to Complete Advance Directives for Residents
Penalty
Summary
The facility failed to complete advance directives for seven residents, resulting in missing or incomplete advance directive forms. Each resident had a physician's order for CPR or full code by default, but no signed documents indicating code status were located in their electronic medical records (EMR). The residents involved had various medical conditions, including cerebral palsy, chronic respiratory failure, chronic kidney disease, heart failure, and type two diabetes, among others. Their cognitive statuses varied, with some being cognitively intact and others having moderate cognitive impairment. Interviews with social workers revealed that there is supposed to be a form signed by the guardian, responsible party, or resident that is uploaded to the EMR to indicate advance directives. However, the social workers were unable to locate these forms in the EMR. The facility's policy states that upon admission, residents should be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive. The policy also requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record. The policy further outlines that if a resident has not established advance directives, the facility staff should offer assistance in establishing them. Despite these policies, the facility did not have the necessary signed documents in place for the residents reviewed, indicating a failure to adhere to their own procedures and potentially impacting the residents' rights to make informed decisions about their care.
Deficiencies in Care Plan Reviews and Resident Care
Penalty
Summary
The facility failed to ensure that reviews and revisions of residents' care plans were made to provide necessary interventions for care and services, affecting five residents. Resident #5 reported missing scheduled showers and inadequate catheter care, with records showing inconsistent documentation of catheter care and missed showers. The care plan indicated a preference for showers three times a week, but the resident only received seven showers in 30 days. Additionally, catheter care was not consistently documented, with several days showing no care provided. Resident #9 experienced significant weight loss, with a recorded drop from 147.2 pounds to 130.1 pounds over 16 days. Despite having a PEG tube for feeding, the care plan lacked documentation of the feeding rate, and no interventions were added following the weight loss. Resident #40 reported issues with shower equipment, leading to inadequate bathing, as the shower chair did not fit, and the tub was reportedly broken. The resident, who required assistance from two staff members, only received three showers in a 30-day period. Residents #78 and #80 also experienced deficiencies in bathing care. Resident #78 was unsure of the frequency of showers and reported being given a washcloth to wash up in the room, with records showing only three showers in a month. Resident #80 appeared unshaven and scruffy, with records indicating only three showers in a 30-day period, despite requiring assistance from two staff members. The facility's policies on comprehensive, person-centered care plans and bathing guidelines were not adhered to, resulting in unmet care needs for these residents.
Failure to Conduct Timely Activity Assessments and Support Voting Rights
Penalty
Summary
The facility failed to conduct and maintain timely activity assessments for eleven residents, as observed during a survey. The deficiency was identified when it was found that activity assessments were not completed quarterly as required by the facility's policy. For instance, Resident #4, who was admitted in May 2024, only had an initial activity assessment completed upon admission, with no subsequent assessments. This lack of regular assessments was consistent across other residents, such as Resident #5, who had no documented assessments since admission in September 2021, and Resident #26, who only had one assessment completed in June 2024. The Activities Director was unaware of the requirement for quarterly assessments, which contributed to the oversight. Additionally, the facility failed to ensure that Resident #4 was able to exercise her right to vote. During a Resident Council meeting, Resident #4 expressed a desire to vote in the upcoming Presidential election, but there was no documentation or follow-up to facilitate this. The Activities Director had noted Resident #4's interest in voting upon admission but did not take further steps to ensure her voting rights were supported. This oversight was contrary to the facility's policy, which encourages residents to exercise their voting rights and mandates assistance for those expressing a desire to vote.
Medication Administration Delays and Backup Source Failures
Penalty
Summary
The facility failed to ensure the timely administration of medications, particularly insulin, to meet the needs of residents with diabetes and other conditions. Multiple residents experienced delays in receiving their insulin, which was often administered hours after the prescribed times. This was observed in several residents, including one who reported receiving morning insulin late and another who experienced significant weight loss potentially due to inconsistent insulin administration. The facility's medication administration policy requires medications to be given within one hour of the prescribed time, but this was not adhered to, leading to multiple instances of late administration documented in the Medication Administration Records (MAR). The report highlights the challenges faced by the facility in managing medication administration due to staffing issues. A Registered Nurse/Infection Preventionist was called in unexpectedly to cover shifts, leading to unfamiliarity with residents and further delays in medication administration. The nurse reported being overworked and not receiving timely communication about shift changes, contributing to the late administration of medications. The facility's Director of Nursing and other managerial staff did not assist with floor duties, exacerbating the staffing shortages and impacting the timely delivery of care. Additionally, the facility failed to retrieve medications from the backup source, resulting in residents not receiving their prescribed medications. One resident did not receive their antidepressant and anti-anxiety medications on multiple occasions due to alleged unavailability, despite these medications being present in the backup supply. This lack of coordination and failure to utilize available resources further contributed to the deficiencies in medication administration and resident care.
Inadequate Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to provide adequate care and services to prevent urinary tract infections for several residents, as evidenced by the lack of consistent catheter care and documentation. Resident #5 reported that her suprapubic catheter was not changed as scheduled, and there were multiple instances where catheter care was not documented. The resident expressed concerns about the risk of infections due to irregular catheter maintenance. The facility's records corroborated these claims, showing gaps in catheter care documentation and missing notes on catheter changes. Resident #40 also experienced issues with catheter care, reporting that her suprapubic catheter was not changed as ordered, leading to a hospital visit for an infection. Observations and record reviews revealed signs of infection at the catheter site, and the resident had to request hospital care. The facility's records showed no documentation of catheter changes despite physician orders, and the resident returned from the hospital with a prescription for antibiotics due to a urinary tract infection. Other residents, including #83, #11, and #81, were observed with urinary catheter bags and tubing in direct contact with the floor, which poses a risk for contamination and infection. Resident #11 reported frequent UTIs and inadequate catheter care due to staffing issues. Observations confirmed that catheter bags were not properly secured, and family members of Resident #81 noted that the catheter bag was consistently found on the floor during visits. These findings indicate a systemic issue with catheter care and infection prevention in the facility.
Inconsistent Nighttime Snack Provision
Penalty
Summary
The facility failed to consistently offer and provide nighttime snacks to residents, resulting in feelings of frustration and unmet needs. Observations, interviews, and record reviews revealed that seven residents were not consistently offered snacks at bedtime, leading to extended periods of time between dinner and breakfast. During a Resident Council meeting, eleven out of twelve residents reported that nighttime snacks were not consistently offered, and staff often claimed that no snacks were available. The Dietary Manager acknowledged awareness of these concerns, which were also documented in resident council and food council notes over the past six months. The facility's policy on snacks did not specify who was responsible for offering and preparing them. A review of nighttime snack documentation showed inconsistencies in offering snacks to residents, with some residents receiving snacks only a few times over a 30-day period. A resident with diabetes expressed concern about not receiving nighttime snacks, which are crucial for managing low blood sugar. Despite a physician's order for diabetic nighttime snacks, records showed that this resident went several consecutive days without receiving a snack. The facility's meal service schedule indicated a 14-hour gap between dinner and breakfast, during which residents were not consistently offered nourishing snacks.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain an effective Antibiotic Stewardship Program, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance among all 84 residents. The facility's Infection Control documentation from December 2023 to October 2024 was incomplete, lacking line listing and Antibiotic Stewardship documentation for several months. The Infection Control Registered Nurse (IC RN) admitted to tracking antibiotic use on a monthly line list but failed to ensure that all residents met the McGeer criteria for antibiotic use. Discrepancies were noted between the number of residents receiving antibiotics and those included in the monthly infection summary, with some residents excluded due to a lack of confirmed infections. The report highlights specific cases where residents received multiple antibiotics without proper documentation or justification. One resident was treated with three different antibiotics for a urinary tract infection, while another received two antibiotics for a UTI, with one discontinued due to an allergy without a specified date. Other residents were treated with antibiotics for conditions such as C-diff, wound infections, and elevated white blood cell counts, but the facility failed to document whether these treatments met the McGeer criteria. The IC RN was unable to provide a clear explanation for these discrepancies and admitted to being unaware of some antibiotic orders until after they were initiated. Resident #58's case exemplifies the facility's failure to ensure appropriate antibiotic use. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease and acute kidney failure, was prescribed Doxycycline for a wound infection without any progress notes or laboratory results to justify the treatment. The Infection Preventionist was unaware of the antibiotic administration and confirmed that the resident did not meet the McGeer criteria for antibiotic usage. The lack of documentation and oversight in this case reflects the broader issues within the facility's antibiotic stewardship practices.
Resident's Right to Refuse Room Change Not Respected
Penalty
Summary
The facility failed to respect a resident's right to refuse a room change, which is a violation of their self-determination and choice. The resident, who is cognitively intact with a BIMS score of 15, expressed feelings of sadness and hopelessness after being moved from the rehabilitation section to the long-term care section without their consent. The resident, who has been at the facility for about six months, was visibly upset and stated that they did not agree to the room change and were unhappy about it. The resident emphasized that they did not plan on staying long-term and were no longer receiving therapy. The facility's policy on room changes, revised in May 2017, states that residents have the right to refuse a room change if it involves moving from a skilled nursing unit to a non-skilled unit, or vice versa, or if the move is solely for staff convenience. Despite this policy, the resident was moved without their agreement, and the reason for the room change was marked as 'other' in the electronic medical record. The social worker interviewed did not recall the resident being upset about the room change, but later documentation confirmed the resident's dissatisfaction with their current placement.
Failure to Provide Adequate Notice of Non-Coverage
Penalty
Summary
The facility failed to provide adequate notice of non-coverage and maintain documentation for two residents, resulting in a lack of full disclosure related to Medicare rights and the inability to appeal the discharge within the time frame allotted by Medicare. For Resident #76, the Notice of Medicare Non-Coverage Form indicated that services would end on 7/21/24, and the form was signed by the resident on the same date. However, for Resident #187, the facility could not provide the Notice of Medicare Non-Coverage Form upon request, despite the resident's discharge date being 7/1/24. Interviews with the Social Worker and Social Services Director revealed that the form for Resident #187 could not be found. The facility Administrator acknowledged awareness of the missing notification form and stated that such forms should be provided at least 48 hours prior to discharge and maintained as part of the medical record.
Inadequate Monitoring and Documentation of Physical Restraint Use
Penalty
Summary
The facility failed to ensure that Resident #75 was free from the use of physical restraints without proper assessment and monitoring. During an initial tour, Resident #75 was observed in a customized chair with a chest harness that had four non-self-release buckles, which the resident could not remove independently. The resident's medical record indicated a physician's order for a postural chest harness, which was discontinued months prior, and there was no new order or consistent monitoring upon the resident's readmission. The care plan and progress notes contained contradictory information regarding the resident's ability to release the harness, and the MDS assessment inaccurately coded the resident as not using physical restraints. Interviews with staff, including the Therapy Director and MDS Coordinator, confirmed that Resident #75 could not release the harness independently, and there was no current physician order for its use. The facility also lacked a physical restraint policy, as reported by the administrator. This lack of assessment, monitoring, and policy adherence resulted in the inappropriate use of a physical restraint on Resident #75, violating the requirement that residents be free from restraints unless medically necessary and properly documented.
Failure to Timely Obtain Weights and Administer Enteral Feeding
Penalty
Summary
The facility failed to obtain timely weights for two residents, resulting in unassessed weight loss. Resident #9 experienced a significant weight loss of 17.1 pounds, equating to an 11.62% decrease over 16 days. Despite having a care plan for malnutrition related to dysphagia, the latest intervention was dated a month prior, and there was no indication of timely re-assessment or intervention following the weight loss. Resident #9 expressed confusion about the weight loss during an interview, indicating a lack of communication and monitoring by the facility. Resident #80 was observed to be thin and had issues with the administration of enteral feeding. The feeding pump was found beeping with an empty bottle, indicating a lapse in feeding schedule adherence. The bottle, which should have been replaced at 4 AM, was left empty until 8:12 AM. The resident's care plan had been revised for significant weight loss following hospitalization, but interventions had not been updated since June 2024. The Corporate Registered Dietitian acknowledged the need for re-weights when requested but did not see the necessity for re-weighing these residents, despite evident weight issues.
Inaccurate Enteral Feeding Orders Lead to Deficiency
Penalty
Summary
The facility failed to ensure the accuracy of enteral feeding orders for a resident, resulting in an incomplete order with the potential for enteral tube malfunction or weight loss. During an observation, it was noted that the resident appeared thin and was receiving a Peractive tube feeding solution at 60cc/hr. A subsequent observation revealed that the resident's peg tube pump was beeping, indicating an issue. The feeding bottle was empty, and a new bottle was set on the overbed table but was not labeled. The RN stated that the night shift leaves the full bottle at the bedside without hanging it, leading to the feeding running longer than intended. A review of the resident's Medication Administration Record showed an order for enteral feeding at bedtime due to dysphagia, with specific instructions for the feeding rate and water flush. However, the order was incorrect in the electronic medical record, lacking documentation for both the hang time and take-down time. The Corporate Clinical Specialist, acting as the DON, confirmed that the order was incorrect and had been written without a take-down time, which was a deviation from the physician's orders. The facility's 'Enteral Nutrition' policy emphasizes providing adequate nutritional support as ordered, but this was not adhered to in this instance.
Failure in Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to implement an effective communication and coordination procedure for a resident requiring dialysis care, leading to a deficiency. The resident, who was severely cognitively impaired and required maximum assistance for daily activities, was admitted with multiple diagnoses including end-stage renal disease with dialysis dependence. The resident's care plan indicated scheduled dialysis sessions twice a week, but there were no completed dialysis communication forms in the resident's electronic medical record. A binder at the nurses' desk contained only blank forms, and it was revealed that completed forms were removed by administration. The deficiency was further highlighted when the resident received duplicate influenza vaccinations due to a lack of communication between the facility and the dialysis center. The resident was administered the vaccine at the facility and again during a dialysis session. The facility's infection control unit manager confirmed the duplication and noted that the vaccination was not entered into the Michigan Care Improvement Registry by either the facility or the dialysis center. The facility's policy on influenza vaccination did not address coordination with the dialysis center, contributing to the communication breakdown.
Failure to Conduct Timely Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed timely monthly medication regimen reviews (MRR) for three residents, resulting in missed reviews and delayed responses to recommendations. Resident #19, who is cognitively intact but has a guardian, did not have an MRR completed in July 2024. Resident #42, with moderate cognitive impairment, also missed an MRR in July 2024, and a recommendation for a gradual dose reduction (GDR) made in March 2024 was not signed off until over two months later. Resident #67, who has dementia and other conditions, had MRRs performed in February and April 2024 with recommendations for dose reductions that were not addressed by the physician until the facility was questioned. The facility's policy requires that MRR findings be communicated within 24 hours and acted upon by the prescriber, but there were no specified timeframes for responses to pharmacy recommendations. The administrator confirmed that the physician did not address the MRRs for Resident #67 from February and April 2024, and the facility was unable to provide a policy indicating appropriate timeframes for the MRR process. This lack of timely response and adherence to policy led to the deficiency noted in the report.
Inadequate Indications and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents had adequate indications for the usage of psychotropic medications, proper care plan implementation, and appropriate monitoring. Resident #75 was observed without a sleep disorder diagnosis, yet was prescribed Zolpidem for sleep issues. The social worker and psychiatric nurse practitioner could not provide documentation supporting the need for this medication, as it was continued from a previous hospital stay without a documented indication for its use. Resident #80 was prescribed Ramelteon for insomnia, but there was no care plan, monitoring, or sleep tracking related to his hypnotic usage. The medication was initially started during a hospital admission and continued upon readmission to the facility. The social worker acknowledged that a care plan and monitoring should have been in place for the resident's hypnotic usage. Resident #82 was on Risperdal, an antipsychotic medication, without documented behaviors justifying its use. The medication was continued from a previous prescription upon admission, and the psychiatric nurse practitioner was uncertain about the indication for its use. The social worker later provided documentation from the FDA regarding Risperdal's use for irritability associated with autistic disorder, but this was not appropriately categorized in the resident's medical record until questioned by the surveyors.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to prevent pre-set up medications from being found in two of five medication carts. During an observation, a registered nurse discovered pre-set up medications, including metoprolol tablets, in an unmarked plastic cup in a medication cart. Additionally, a licensed practical nurse was observed handling medication without performing hand hygiene and found two medication cups with crushed and whole tablets in a cart drawer, lacking proper identification or resident names. The facility also failed to prime a new insulin pen before administration. An LPN on the secure dementia unit was observed administering insulin to a resident without priming the new insulin pen, which is necessary to ensure the pen is working correctly and to avoid incorrect dosing. Furthermore, the facility did not provide timely insulin administration per a physician's order for a resident. The resident reported receiving morning insulin late, which was confirmed by a review of the medication administration record showing multiple instances of late insulin administration. The RN responsible for the late administration cited staffing issues and last-minute schedule changes as contributing factors to the delay.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide dental services to a resident, identified as R19, who had not received routine dental care since their admission. R19, a cognitively intact individual with a BIMS score of 13, expressed a desire to see a dentist, noting they had not seen one since arriving at the facility. Despite having a guardian due to the inability to make their own medical decisions, R19 had a dental consent form in their electronic medical record, signed and dated, but the sections to consent to or decline dental care services were left blank. Interviews with facility staff revealed that R19 had not been seen by a dentist during their stay. The social worker, SW S, confirmed that R19 was only recently placed on a list to be seen by the dentist, indicating a lapse in routine dental care provision. The facility's policy on dental services, which includes providing routine and emergency dental services through various means, was not adhered to in this case, resulting in the deficiency.
Failure in Vaccination Administration Procedures
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures for vaccination administration, affecting three residents. Resident #1 expressed a desire to receive both the Influenza and Pneumonia vaccines. While the Influenza vaccine was administered, the Pneumonia vaccine was not, despite being ordered. The failure was attributed to the floor nursing staff not administering the vaccine as ordered. Resident #56's documentation showed discrepancies between the vaccine ordered and the vaccine education provided. Although Prevnar 20 was ordered and administered, the documentation incorrectly noted Prevnar 13, and there was no documentation of follow-up monitoring after administration. The facility also failed to document the Vaccine Information Statement (VIS) version provided. Resident #75 wanted the Pneumonia vaccine, but it was never administered, despite being available and ordered. There was no documentation explaining why the vaccine was not given. The facility's policy requires that all residents be offered pneumococcal vaccines and that documentation should include the date of vaccination, lot number, expiration date, person administering, and site of vaccination. However, these procedures were not followed, leading to the deficiency.
Inadequate Supervision and Reporting of Non-Consensual Sexual Behavior
Penalty
Summary
The facility failed to implement and operationalize abuse prohibition policies and procedures, resulting in inadequate supervision to prevent non-consensual sexual behaviors between two cognitively-impaired residents in the locked Dementia Unit. The incident involved two residents who were found partially naked in bed with genitals exposed. The facility did not report or investigate the incident in a timely manner, as the Administrator and DON were informed two days after the event occurred. Resident #705, a female with bipolar disorder, major depressive disorder, disorganized schizophrenia, and dementia, was moderately cognitively impaired and had a legal guardian. She was found in bed with Resident #706, a male with Alzheimer's disease and dementia, who was severely cognitively impaired. Both residents were deemed incompetent and unable to make informed decisions. The facility's documentation revealed that Resident #705 had previously exhibited behaviors of offering intercourse with other residents, and Resident #706 had a history of attempting to bring female residents into his room. Interviews with staff indicated that the residents were found by CNAs during a night shift, and the incident was not immediately reported to the DON or Administrator. The facility's investigation was initiated two days later, and there was a lack of comprehensive documentation, including a police report, staff schedule, and camera footage timeline. The facility's investigation concluded that the allegation could not be substantiated, but the lack of timely reporting and supervision contributed to the deficiency.
Failure to Honor Resident's DNR Wishes Due to Incomplete Documentation
Penalty
Summary
The facility failed to honor the resident's wishes and identify the designated patient advocate, despite legal documentation provided by the family upon admission. This resulted in a resident receiving CPR for over an hour and subsequently dying, contrary to the resident's Do Not Resuscitate (DNR) wishes. The resident had a BIMS score of zero, indicating severe cognitive impairment, and had appointed her husband as the primary patient advocate and her daughter as the successor. However, the facility did not recognize these designations due to incomplete documentation. The facility's failure to complete the necessary Incapacity to Make Health Care Decisions Form, which required signatures from two physicians, led to the resident being treated as a Full Code. Despite the presence of a signed DNR order by the designated patient advocate, the facility deemed it invalid because the form lacked dates and the incapacity form was not completed in a timely manner. This oversight resulted in the resident's DNR wishes not being honored, as the facility continued to treat her as a Full Code. The facility's policies did not clearly outline the process for determining a resident's incapacity and the authority of a patient advocate. The Director of Nursing acknowledged the error in not filling out the forms correctly, and the Director of Social Services confirmed the delay in obtaining the necessary physician signatures. The facility's failure to adhere to its own policies and procedures regarding patient advocacy and decision-making authority contributed to the deficiency, ultimately leading to the resident's undesired resuscitation and death.
Failure to Report and Investigate Missing Resident
Penalty
Summary
The facility failed to adhere to its policy for immediately reporting, investigating, and informing local authorities about a missing resident, resulting in a deficiency. Resident #802, who had a medical history including osteomyelitis requiring IV antibiotic therapy, diabetes, and other conditions, left the facility and did not return for over 24 hours. The resident's absence was not reported to the Administrator or the Director of Nursing (DON) until the morning after the resident was discovered missing. Despite the resident's failure to return, the facility did not notify local authorities or the state agency as required by their policy. The Administrator and DON were unaware of the resident's absence until the morning stand-up meeting, and no staff member had notified them of the situation. The facility attempted to contact the resident through phone calls and by visiting the last known address, but these efforts were unsuccessful. The Administrator and DON personally searched for the resident but did not report the incident to the police or state agency, as they did not consider it an elopement due to the resident's alert and oriented status and ability to leave on Leave of Absence (LOA) status. The facility's policies, including the Signing Residents Out Policy and the Elopement Policy, were not followed. The resident did not sign out upon leaving, and no investigation was conducted to determine if the case was reportable. The facility's policy required a search and notification of authorities if a resident could not be located, but these steps were not taken. The lack of adherence to these policies resulted in a deficiency, as the facility did not ensure the resident's safety or report the incident as required.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to significant deficiencies. For one resident, the facility did not appropriately address the resident's Advanced Directive. The resident was admitted with severe cognitive impairment, as indicated by a BIMS score of zero. Despite this, the facility did not complete the necessary DO-NOT-RESUSCITATE (DNR) form correctly, and the incapacity determination was not signed timely by two physicians. Consequently, the resident's code status remained Full Code, and the DNR order was voided. The resident received CPR and was pronounced dead before the family could sign the DNR order form. For another resident, the facility failed to address the resident's frequent Leaves of Absence (LOA) in the care plan. This resident had a history of mental illness and was receiving treatment for various conditions, including osteomyelitis and HIV. The resident often left the facility during the day and returned at night, but on one occasion, did not return after midnight. The facility did not report the resident as missing to local authorities or the state agency, as they considered the resident to be on LOA. The care plan did not include interventions or actions to monitor and maintain the resident's safety during these absences. The facility's policies on Advanced Directives and care planning were not adhered to, as evidenced by the lack of a care plan for the Advanced Directive and the absence of a care plan addressing the frequent LOA for the second resident. The facility did not provide the Care Planning Policy during the survey exit, further indicating a lack of compliance with established procedures.
Failure to Honor DNR Order Leads to Unwanted CPR
Penalty
Summary
The facility failed to honor the Do Not Resuscitate (DNR) wishes of a resident, resulting in the resident receiving full code status and undergoing Cardiopulmonary Resuscitation (CPR) against the expressed wishes of the resident's designated patient advocate. The resident, who had severe cognitive impairment with a BIMS score of zero, was found unconscious by a nurse, and CPR was initiated by the staff until emergency medical personnel arrived. The resident's family, including the designated patient advocate, was not notified of the resident's declining condition and witnessed the CPR being performed, which was contrary to the resident's documented DNR order. The deficiency arose from the facility's failure to properly process and validate the resident's DNR status. Although the resident's husband was designated as the patient advocate and had signed the DNR order, the facility did not complete the necessary incapacity form in a timely manner, which required signatures from two physicians. This delay resulted in the resident being treated as a full code, as the facility did not recognize the DNR order due to the missing physician signatures. The facility's Director of Nursing acknowledged the oversight and the delay in obtaining the required documentation. Interviews with staff revealed that there was confusion and a lack of communication regarding the resident's code status. The staff relied on the electronic medical record, which incorrectly indicated a full code status, leading to the initiation of CPR. The facility's policies on determining a resident's healthcare decision-making authority and the process for activating a patient advocate's authority were not effectively implemented, contributing to the failure to honor the resident's advance directives.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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