Applewood Nursing Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodhaven, Michigan.
- Location
- 18500 Van Horn Rd, Woodhaven, Michigan 48183
- CMS Provider Number
- 235375
- Inspections on file
- 29
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Applewood Nursing Center, Inc during CMS and state inspections, most recent first.
The facility failed to maintain an adequate emergency food supply, using it as part of the daily food stock. Essential items like canned beans, tuna, and chicken were missing from the emergency menu. The FSD could not specify the required inventory levels, and the NHA acknowledged the deficiency without providing further documentation.
The facility failed to maintain a clean environment for two residents with tube feeding systems, resulting in soiled tube feeding poles and areas around the residents. The DON stated that all staff were responsible for cleaning spills, but the deficiency was not addressed until after surveyors' observations.
A resident with multiple sclerosis and a leaking indwelling urinary catheter experienced worsening and infection of a sacral Stage 4 pressure ulcer due to the facility's failure to address the catheter issue. Despite awareness of the problem, the facility did not ensure the resident received a necessary urology appointment, which was canceled due to insurance issues. The facility's care plans and policies did not adequately address the situation, leading to a lack of timely intervention.
A resident with multiple sclerosis and a neurogenic bladder experienced a chronic leaking foley catheter, contributing to a sacral wound reopening. Despite awareness of the issue, the facility delayed scheduling a urology appointment due to insurance problems, and staff acknowledged the catheter's role in the wound's infection and stalled healing. The facility's policy on catheter care was not followed, and the nursing home administrator admitted responsibility for the delayed appointment.
A resident's catheter bag was left uncovered and visible from the hallway, compromising their dignity and privacy. The resident, who has intact cognition and a medical history of obstructive and reflux uropathy, expressed discomfort about the situation. A CNA and the DON acknowledged that catheter bags should be covered to maintain dignity, as per facility policy.
A facility failed to update care plans for a resident with a PEG tube, leading to multiple hospital admissions for tube reinsertion. The resident, with conditions such as hemiplegia and dysphagia, had no care plans addressing tube manipulation or fluid restrictions. Despite multiple hospital transfers, the care plan was not revised, and the Director of Nursing acknowledged the oversight without explanation.
A resident with a PEG tube experienced multiple hospital transfers due to tube dislodgement and blockage. Despite being cognitively intact and requiring assistance with ADLs, the facility failed to implement timely interventions to prevent these issues. The DON was unaware of specific measures to address the problem, and an abdominal binder was not considered until after several hospitalizations. No psychiatric consultation was sought despite concerns about the resident's behavior.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness. Staff members were observed not using hand barriers after washing hands, and hot food items were not held at required temperatures. Additionally, staff did not wash hands before donning gloves after handling various surfaces and food items.
The facility failed to ensure dignity for four residents by serving meals with plastic ware and styrofoam containers. Observations and interviews revealed that residents received meals with improperly positioned domes or uncovered food, and expressed concerns about the use of plastic utensils and lack of proper food covering. The Certified Dietary Manager was unaware that this was a dignity concern.
The facility failed to ensure proper nail care and provide appropriate briefs for incontinence care, resulting in unmet hygiene needs and residents being left soiled for extended periods. One resident had long, dirty fingernails and self-inflicted scratches, while others reported a consistent shortage of appropriate-sized briefs, leading to prolonged periods of being left wet and soiled. Staff confirmed the inconsistency in the availability of briefs, despite regular orders.
The facility failed to ensure meals were served at a preferred and palatable temperature for four residents, resulting in complaints of cold food and dissatisfaction with meals. Meals were observed being delivered without domes or coverings, and the Certified Dietary Manager was unaware of the complaints.
The facility failed to maintain the garbage storage area in sanitary conditions, with exterior trash dumpsters observed with open lids and bagged trash and debris present. Both the Environmental Services Director and Dietary Manager acknowledged the issue, indicating a lack of proper oversight and maintenance.
The facility failed to maintain a clean and clutter-free environment for two residents, resulting in soiled and cluttered rooms. One resident's room had a soiled curtain and fall mat, while another resident's room was cluttered with various items and had a sticky substance attracting gnats. Staff acknowledged the issues but did not take immediate action.
The facility failed to ensure PASARR forms for Mental Illness/Intellectual Disability/Related Conditions were reviewed, revised, and sent for annual evaluation for two residents. One resident had diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder, while the other had a diagnosis of bipolar disorder. The Social Service Director and Director of Nursing admitted to not following up on the evaluations.
The facility failed to secure two medication carts, leaving them unlocked and unattended, with medications accessible. Interviews confirmed that medication carts should be locked when not attended by nursing staff, as per facility policy.
The facility failed to ensure that a resident's foley catheter tubing did not drag along the floor during ambulation in a wheelchair. Despite staff adjustments, the tubing remained on the floor, posing a risk of getting trapped under the wheelchair wheel. Interviews with the Unit Manager and DON confirmed that the tubing should not have been on the floor, indicating a lapse in proper catheter care and monitoring.
The facility failed to post appropriate isolation directions for a resident with C. Diff and staff did not follow proper contact precautions, including the use of PPE and handling of contaminated items.
A facility failed to implement a skin care plan for a resident with discitis and moderate risk for skin breakdown upon admission. The resident had redness on the buttocks and required extensive assistance with mobility, necessitating a skin care plan. Despite these needs, no baseline care plan was established, as confirmed by the DON.
The facility failed to ensure the confidentiality of residents' electronic medical records. Observations revealed that two residents' records were visible on medication cart computer screens with no nurse in attendance. Interviews with staff confirmed that this was against the facility's policy, which requires computer terminals to be shut off when not in use.
The facility failed to consistently administer wound care treatments for a resident with idiopathic scoliosis and muscle weakness, leading to a deficiency in pressure ulcer care. Observations and interviews revealed discrepancies in the documentation and administration of wound care treatments, with missed administrations on multiple dates and incorrect dating of dressings. The DON acknowledged that treatments not signed off would be considered not done, highlighting a failure in adhering to the facility's wound care policy.
Inadequate Emergency Food Supply in Facility
Penalty
Summary
The facility failed to maintain an adequate supply of emergency food, as evidenced by the absence of several items listed on their emergency menu. During an observation and interview with the Food Service Director (FSD), it was revealed that the facility was using its emergency food stock as part of its daily food supply. The emergency food supply, which should consist of canned and shelf-stable items, was stored in the dry food storage room. However, upon review, it was found that essential items such as canned kidney beans, green beans, tuna, beets, chicken, carrots, ravioli, and waxed beans were missing from the emergency stock for the first three days of the emergency menu. The facility's emergency menu, dated 2019, outlines the requirement for a plan to provide subsistence for all persons in the event of an emergency, utilizing shelf-stable items that do not require refrigeration or cooking. The document also specifies that the emergency stock should be inventoried routinely, with items below par level replenished and those nearing expiration replaced. Despite these guidelines, the FSD was unable to provide information on the minimum inventory levels required for the emergency stock. The Nursing Home Administrator acknowledged the deficiency, stating that the facility should have maintained an emergency food supply that aligns with the menu. No additional documentation or information was provided during the exit conference to address this deficiency.
Failure to Maintain Clean Environment for Residents with Tube Feeding
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, resulting in an unclean and unsanitary environment. Observations revealed that both residents had tube feeding systems that were not properly maintained. One resident was observed with a tube feeding pole and base, a fall mat, and the floor heavily soiled with encrusted tube feeding formula. Another resident's tube feeding pole and base were also soiled with dried formula. The Unit Manager, RN C, acknowledged the unacceptable condition, noting that the dried formula appeared to have been present for an extended period. The Director of Nursing (DON) stated that it was the responsibility of all staff to keep the tube feeding poles clean and that nurses should clean any spillage they observe. However, the DON also mentioned that housekeeping was responsible for cleaning spots on the wall and spills, which should include cleaning the tube feeding poles. Despite these responsibilities, the deficiency was not addressed until after the surveyors' observations, and no additional documentation or information was provided by the Nursing Home Administrator or DON during the exit conference.
Failure to Address Leaking Catheter Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to implement necessary interventions for a resident with a chronic leaking indwelling urinary catheter, which contributed to the worsening and infection of a sacral Stage 4 pressure ulcer. The resident, who had multiple sclerosis and neuromuscular dysfunction of the bladder, reported issues with the catheter leaking, which was documented in their electronic health record. Despite the resident's need for a urology appointment to address the catheter issue, the appointment was canceled due to a lack of insurance, and the resident's condition worsened as a result. Observations and interviews revealed that the resident's catheter had been leaking for several months, and the facility staff, including a registered nurse and licensed practical nurses, were aware of the issue. The leaking catheter was identified as a contributing factor to the resident's wounds not healing and becoming infected. Despite this knowledge, the facility did not take timely action to address the catheter issue or ensure the resident received the necessary medical evaluation. The facility's care plans and policies did not adequately address the resident's leaking catheter, and there was a lack of coordination to resolve the insurance issue and reschedule the urology appointment. Interviews with facility staff, including the business office manager and the director of nursing, highlighted a breakdown in communication and responsibility, as the facility did not take steps to pay for and reschedule the urology appointment, which was acknowledged as their responsibility.
Failure to Provide Comprehensive Foley Catheter Care
Penalty
Summary
The facility failed to provide comprehensive foley catheter care for a resident, resulting in a chronic leaking catheter and concerns about a sacral wound reopening. The resident, who has multiple sclerosis and a neurogenic bladder, was observed with a leaking catheter and reported that it had contributed to the reopening of a sacral wound. The resident's electronic health record indicated a history of pressure ulcers and a need for extensive assistance with bed mobility. Despite the resident's ongoing issues with the catheter, a scheduled urology appointment was canceled due to insurance issues, and the resident was not seen by a urologist for several months. Interviews with facility staff, including a registered nurse, a licensed practical nurse, and the business office manager, revealed that the facility was aware of the resident's leaking catheter and the insurance issues preventing a urology visit. The staff acknowledged that the leaking catheter contributed to the wounds not healing and becoming infected. The facility's policy on indwelling catheter care indicated that catheters should be changed upon clinical indication of infection or obstruction, but this was not adhered to in the resident's case. The nursing home administrator agreed that it was the facility's responsibility to schedule and pay for the urology appointment, which was eventually scheduled months later.
Failure to Maintain Catheter Bag Privacy
Penalty
Summary
The facility failed to maintain catheter bag privacy for a resident, identified as R411, which compromised their dignity and privacy. On multiple occasions, R411's catheter bag was observed hanging on the side of the bed, clearly visible from the hallway and to passersby, without a privacy bag. This visibility was noted at different times on the same day, and the resident expressed discomfort and embarrassment about the situation, especially in the presence of visitors. R411's medical history includes obstructive and reflux uropathy and obesity, and they have intact cognition as indicated by a BIMS score of 15/15. A Certified Nursing Assistant acknowledged the lack of a privacy bag and confirmed that catheter bags should be covered to maintain resident dignity. The facility's Director of Nursing also stated that the expectation is for catheter bags to be covered by a privacy bag, in line with the facility's policy on indwelling catheter care and maintenance.
Failure to Revise Care Plans for Resident with Tube Feeding
Penalty
Summary
The facility failed to develop, implement, and revise care plans for a resident with a tube feeding, resulting in multiple hospital admissions for PEG tube reinsertion. The resident, who was admitted with diagnoses including hemiplegia, vascular dementia, dysphagia with a J/G tube, end-stage renal disease, and hypotension, was cognitively intact and required assistance with activities of daily living. Despite being NPO and receiving tube feeding for nutritional needs, the care plan did not address the resident's behavior of manipulating the PEG tube or the fluid restrictions for enteral feeding and water flushes. Additionally, there were no interventions to reduce the frequency of hospital transfers for PEG tube care. The care plan, dated several months prior, focused on the risk of aspiration due to dysphagia and noncompliance with head-of-bed positioning but had not been updated or revised following the resident's multiple hospital transfers. The Director of Nursing acknowledged the oversight in revising the care plans after each hospital transfer but did not provide an explanation for the lack of identification of this issue as a concern. The facility's care plan policy indicated that any member of the interdisciplinary team could request a special care conference if an issue needed to be addressed, but this was not done in this case.
Failure to Prevent PEG Tube Dislodgement
Penalty
Summary
The facility failed to implement timely interventions to prevent the dislodgement and manipulation of a percutaneous enteral gastrostomy (PEG) tube for a resident, resulting in multiple hospital transfers. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of hemiplegia, vascular dementia, and was NPO, receiving nutrition through a tube. Despite repeated hospitalizations for PEG tube dislodgement and blockage, the facility did not effectively address the issue. The resident was transferred to the hospital on multiple occasions over several months for the same problem, indicating a lack of adequate intervention. Interviews and record reviews revealed that the facility's Director of Nursing (DON) was unaware of specific interventions to prevent the resident from manipulating or dislodging the feeding tube. Although the use of an abdominal binder was eventually considered, it was not implemented until after numerous hospital transfers. The facility's investigation into the issue did not provide a clear explanation for the delay in addressing the problem, and there was no evidence of a referral for psychiatric consultation despite concerns about the resident's behavior. The facility's failure to implement effective interventions led to repeated hospitalizations for the resident.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to an increased potential for cross-contamination of food and foodborne illness. Multiple staff members, including dietary aides and the dietary manager, were observed not using a hand barrier to shut off the faucet after washing their hands. This was observed on several occasions, and the facility's hand hygiene policy did not detail the expectations for staff working with food. The U.S. Public Health Service 2017 Food Code specifies the need for using disposable paper towels or similar clean barriers to avoid recontaminating hands, which was not followed by the staff in this facility. During a facility tour, it was observed that hot food items were not held at the required temperatures. Scrambled eggs and hashbrowns were found holding at temperatures below the minimum hot holding requirement of 135 degrees F. The dietary manager acknowledged the issue but did not provide an immediate solution. Additionally, during meal service, a dietary aide was observed not taking temperatures before serving, and the dietary manager had to intervene to check the temperatures, which were found to be below the required levels. Furthermore, staff members were observed not washing their hands before donning gloves after handling various surfaces and food items. This was observed multiple times with different staff members, including dietary aides and the cook. The facility's policies did not detail the hand hygiene expectations for staff working with food, and the U.S. Public Health Service 2017 Food Code specifies the need for handwashing before engaging in food preparation and before donning gloves, which was not adhered to by the staff in this facility.
Failure to Ensure Dignity in Meal Service
Penalty
Summary
The facility failed to ensure dignity for four residents on unit 200 by serving meals with plastic ware and styrofoam containers. Observations revealed that residents who ate in their rooms received meals with domes that were not positioned correctly or with food that was not covered during transport. Residents expressed concerns about the use of plastic utensils and the lack of proper food covering, indicating a preference for regular silverware and covered food. One resident mentioned that plastic utensils were not sturdy enough to cut food properly, and another resident noted that they were always the last to be served and had to use plastic ware and paper goods. Interviews with the Certified Dietary Manager revealed that staff sometimes ran out of silverware, but the manager was unaware that this was a dignity concern for the residents. The facility's policy on dignity, revised in April 2024, did not address dietary concerns related to dignity. The observations and interviews highlighted a consistent issue with the use of plastic ware and styrofoam containers, which affected the residents' dining experience and sense of dignity.
Deficiency in Nail Care and Incontinence Supplies
Penalty
Summary
The facility failed to ensure proper nail care and provide appropriate briefs for incontinence care for several residents, resulting in unmet hygiene needs and residents being left soiled for extended periods. Resident R128 was observed with long, dirty fingernails and self-inflicted scratches on the face. The resident confirmed that nail care was only performed during weekly showers, contrary to the Director of Nursing's statement that nail care should occur daily. The care plan for R128 did not address nail care, despite the resident's dependence on staff for all activities of daily living due to moderate cognitive impairment and other medical conditions such as aphasia and cerebral infarction. Resident R25 reported a consistent shortage of appropriate-sized briefs, leading to prolonged periods of being left wet and soiled. The resident and a roommate confirmed that aides often borrowed briefs from other residents, resulting in a lack of supplies when needed. Observations of the supply room and linen cart confirmed the absence of 2X-large and 3-4X-large briefs. The unit clerk responsible for ordering supplies stated that orders were made twice a week, but the amount ordered had not changed, despite the ongoing shortage. R25's medical history includes diabetes, Parkinson's disease, and peripheral vascular disease, and the resident requires assistance for activities of daily living. Other residents, including R15 and R7, also reported issues with the availability of appropriate briefs. R15 described having to use makeshift briefs due to the lack of medium-sized briefs and expressed concern for other residents who could not voice their frustrations. R7 mentioned buying personal briefs due to the facility's shortage and being left wet multiple times. Interviews with staff, including an LPN and the unit clerk, confirmed the inconsistency in the availability of briefs, despite regular orders. The Nursing Home Administrator acknowledged the facility's responsibility to provide adequate supplies and ensure residents are not left wet for extended periods.
Failure to Serve Meals at Preferred Temperature
Penalty
Summary
The facility failed to ensure meals were served at a preferred and palatable temperature for four residents, resulting in complaints of cold food and dissatisfaction with meals. During a breakfast meal observation, residents voiced concerns that their meals were always cold when delivered to their rooms. The meals were observed being delivered without domes or coverings, contributing to the temperature issue. One resident stated there was no place to have meals reheated or warmed, and other residents shared similar concerns. Another resident mentioned that they could no longer receive certain hot food items like hot dogs or hamburgers and resorted to ordering food from outside the facility. During a lunch meal observation, a resident's meal tray was used as a test tray, and the temperatures of the food items were found to be significantly below acceptable levels. The Certified Dietary Manager confirmed that the facility no longer offered hamburgers on the menu and was unaware of the residents' complaints about cold food. The residents involved were all cognitively intact, with a Brief Intellectual Mental Status score of 15/15, indicating they were fully aware of the issue and able to communicate their dissatisfaction clearly.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the garbage storage area was maintained in sanitary conditions, resulting in an increased potential for the harborage and feeding of pests. During a tour of the facility, the surveyor observed exterior trash dumpsters with lids in the open position and a variety of bagged trash and debris in the area. When inquired, the Environmental Services Director acknowledged the issue and mentioned the absence of a waste disposal policy. Similarly, the Dietary Manager was unsure about the state of the area, suggesting a lack of proper oversight and maintenance. The 2017 U.S. Public Health Service Food Code mandates that receptacles and waste handling units for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment, which was not adhered to in this case.
Failure to Maintain Clean and Clutter-Free Environment
Penalty
Summary
The facility failed to ensure a clean and clutter-free homelike environment for two residents, resulting in soiled and cluttered resident rooms. Resident R27's room was observed with a soiled curtain divider and a cracked, soiled fall mat. Despite the resident's moderately impaired cognition, the soiled items were not addressed promptly. Housekeeping and environmental staff acknowledged the issues but did not take immediate action to clean or replace the soiled items. The Nursing Home Administrator also agreed that these items should be cleaned or replaced in a timely manner but did not ensure it was done promptly. Resident R88's room was found to be cluttered with soiled clothes, bags of groceries, over-the-counter medications, blankets, shoes, assistive devices, and cardboard boxes. The clutter extended from the entrance of the room to the pathway of the roommate's bed, and a sticky substance on the floor was attracting gnats. Despite being cognitively intact and using a wheelchair, R88 was informed by the Environmental Supervisor that she had to clean the room herself, which she was unable to do. The Environmental Supervisor acknowledged the need for cleaning but did not provide an alternative solution for the storage of clutter.
Failure to Complete PASARR Evaluations
Penalty
Summary
The facility failed to ensure the Preadmission Screening/Annual Resident Review (PASARR) forms for Mental Illness/Intellectual Disability/Related Conditions Identification (DCH-3877) were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for two residents. Resident 7, admitted on 5/25/2018 and most recently readmitted on 1/29/2024, had diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder. A review of Resident 7's electronic medical record did not reveal a Level II evaluation or a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. The Social Service Director admitted that the previous social worker did not request the Level II evaluation after entering the 3877 form and did not follow up when no one came to do the evaluation. Resident 31, admitted and readmitted on unspecified dates, had a diagnosis of bipolar disorder. A review of Resident 31's electronic medical record revealed that a Level II evaluation had not been completed on either admission. The Director of Nursing reported that when the 3877/78 form was submitted on 9/22/2023, she was not aware that a request for evaluation had to be made and did not follow up when a Level II evaluation was not received in a timely manner. The facility's PASARR policy, last revised in 7/2018, needed updating to reflect changes in submitting 3877/78 forms and requesting Level II evaluations.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to provide adequate supervision for two unlocked medication carts out of nine. On 4/30/24 at 6:30 AM, a medication cart on Station Two was observed unlocked and unattended, with medication drawers accessible. On 5/2/24 at 8:45 AM, another unlocked medication cart on Station Three was observed with medications on top of the cart, in an area with approximately 10 residents. Interviews with the Unit Manager and the Director of Nursing confirmed that medication carts should be locked when not attended by nursing staff. The facility's policy on Medication Administration, last reviewed in 11/2021, also states that medication carts should never be left open and unattended.
Failure to Prevent Catheter Tubing from Dragging on Floor
Penalty
Summary
The facility failed to ensure that the foley catheter tubing for a resident did not drag along the floor during ambulation in a wheelchair. On multiple occasions, the resident was observed with the catheter tubing on the floor, including in the dining area and while wheeling independently through the hall. Despite a staff member adjusting the catheter bag, the tubing remained on the floor, posing a risk of getting trapped under the wheelchair wheel. The resident's clinical record indicated cognitive impairment and a need for partial to moderate assistance with activities of daily living, and the care plan documented the presence of an indwelling catheter due to obstructive uropathy. Interviews with the Unit Manager and the Director of Nursing revealed uncertainty about why the tubing was on the floor and confirmed that it should not have been. The Unit Manager mentioned the resident had an anchor but was unsure if the lack of an anchor was the reason for the tubing being on the floor. The Director of Nursing acknowledged that the tubing should never be on the floor, indicating a lapse in proper catheter care and monitoring for the resident.
Failure to Follow Isolation Protocols for C. Diff Resident
Penalty
Summary
The facility failed to post the appropriate directions for isolation care for a resident (R32) who was in isolation for Clostridium Difficile (C. Diff). On observation, a sign titled Enhanced Barrier Precautions was posted on R32's door, which did not align with the physician's order for Contact Isolation. The Infection Preventionist acknowledged the discrepancy between the posted sign and the facility's policy for C. Diff isolation, which requires handwashing with soap and water before leaving the isolation room. Additionally, the sign on R32's door incorrectly indicated the use of hand sanitizer instead of soap and water for hand hygiene. Further observations revealed that a Certified Nursing Assistant (CNA) failed to follow proper contact precautions when delivering and removing lunch trays from R32's room. The CNA did not don gloves or a gown before entering the room and did not handle R32's dirty dishes separately from other residents' dishes. The facility's policy for Transmission-Based/Contact Precautions and Clostridium Difficile requires staff to wear gowns and gloves for all interactions with the resident and to use disposable or dedicated patient-care equipment. The Director of Nursing and a Registered Nurse confirmed the need for appropriate PPE use and the proper handling of contaminated items to prevent cross-contamination.
Failure to Implement Skin Care Plan Upon Admission
Penalty
Summary
The facility failed to implement a skin care plan upon admission for a resident diagnosed with discitis, who was at moderate risk for skin breakdown. Upon admission, the resident had redness on the bilateral buttocks, indicating a need for immediate skin care intervention. The Minimum Data Set (MDS) assessment showed the resident required extensive assistance with bed mobility and transfers, further emphasizing the need for a skin care plan. Despite these indicators, the facility did not establish a baseline care plan for skin integrity at the time of admission. The Director of Nursing acknowledged that a care plan should have been implemented given the resident's condition and risk factors.
Failure to Ensure Confidentiality of Residents' Electronic Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of residents' electronic medical records for two residents. During an observation on Station Two, one resident's electronic medical record was visible on a medication cart computer screen with no nurse in attendance, allowing any passerby to see the confidential information. Similarly, on Station Three, another resident's electronic medical record was visible on a medication cart computer screen with no nurse in attendance, with approximately 10 residents in the area at the time. Interviews with the Unit Manager and Director of Nursing confirmed that residents' electronic medical records should not be visible to others. The facility's policy on confidentiality, last reviewed in November 2022, states that computer terminals should be shut off when not in use.
Failure to Consistently Administer Wound Care Treatments
Penalty
Summary
The facility failed to consistently administer wound care treatments for a resident, leading to a deficiency in pressure ulcer care. The resident, who had diagnoses of idiopathic scoliosis and muscle weakness, required extensive assistance with Activities of Daily Living (ADLs) and had intact cognition. During a wound care observation, it was noted that the foam dressings on the resident's heels were dated 4/27/24, but the treatment administration record (TAR) indicated that the dressings were applied on 4/28/24. Additionally, there were missed administrations of wound care treatments on multiple dates, including 4/13/24, 4/22/24, and discrepancies in the documentation of wound care on 4/30/24. Interviews with the nursing staff and the Director of Nursing (DON) revealed that wound care should be administered as ordered by the physician and should not be signed off if not completed. The DON acknowledged that if a treatment is not signed off, it would be considered not done. The facility's policy on dressing application, last reviewed in January 2022, required documentation on the electronic health record (EHR) or treatment administration record sheet that the dressing was completed. The failure to consistently administer and accurately document wound care treatments led to the deficiency in pressure ulcer care for the resident.
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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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