Ashley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashley, Michigan.
- Location
- 103 West Wallace Street, Ashley, Michigan 48806
- CMS Provider Number
- 235532
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Ashley Healthcare Center during CMS and state inspections, most recent first.
A resident on hospice with intact cognition and full-code status experienced a progressive decline over several days, with documentation of lethargy, difficulty arousing, poor oral intake, inability to swallow, shallow respirations, and eventual unresponsiveness. Nursing notes showed that hospice and the resident’s son were contacted about the declining condition and code status, and hospice confirmed awareness of the full-code status and the need to send the resident out if required. Despite these changes, there was no evidence of acute assessments or systematic monitoring in the EMR, and vital signs were recorded only a few times over a two-week period. The resident continued to decline until being transferred to the hospital, where she was found in respiratory failure with pneumonia, COVID-19, severe acidosis, hyperkalemia, and septic shock. The DON later acknowledged that there was no acute assessment or monitoring documented and that the resident should have been transferred sooner.
A resident with a history of severe neurocognitive and psychiatric disorders exhibited escalating aggression, including physical and verbal abuse toward staff and other residents. Despite repeated incidents, the care plan was not updated in a timely manner, enhanced supervision was not implemented, and the interdisciplinary team was not notified. Another resident was physically assaulted, and the facility failed to investigate or report the incident as required by policy.
A resident with a history of psychiatric and behavioral issues was alleged to have hit her roommate, but the incident was not reported or investigated according to facility policy. The nurse involved believed the interaction was playful and did not notify the abuse coordinator or administrator, resulting in a failure to follow required abuse reporting procedures.
A resident with a history of rolling out of bed was left unattended with the bed raised, contrary to care plan interventions requiring the bed to be in the lowest position and the call light within reach. The resident fell from the bed and sustained a femur fracture when a CNA left the bedside to retrieve a lift, and observations confirmed that fall prevention measures were not consistently followed.
A resident with a gastrostomy and on Enhanced Barrier Precautions (EBP) did not receive proper infection control measures during incontinence care, as staff failed to wear required gowns. Staff interviews revealed confusion about when EBP should be applied, despite facility policy and signage indicating that gown and gloves are necessary for high-contact care activities.
A resident with severe cognitive impairment suffered a fall resulting in a fractured hip, but staff failed to promptly assess and manage pain, did not initiate appropriate mobility interventions, and delayed emergency medical treatment. The resident received only acetaminophen for severe pain, and the care plan was not updated to address new risks or interventions. An x-ray was not completed before hospital transfer, and documentation inconsistencies were noted.
The facility failed to monitor and store insulin properly, resulting in the presence of outdated and discontinued Novolin N insulin in the medication room refrigerator. The insulin, opened on 9/1/24, was not discarded as required, despite being discontinued. This oversight contradicts the facility's medication storage policy and the manufacturer's guidelines, risking the administration of outdated medication to residents.
The facility failed to maintain proper infection control procedures for residents in COVID-19 isolation, with room doors left open and staff not adhering to PPE protocols. Observations revealed staff wearing inappropriate masks and lacking required eye protection, contrary to the facility's policy. The DON acknowledged the need for proper PPE use, yet lapses were evident.
A resident with heart and kidney failure under hospice care was found with signs of dehydration, including dry lips and skin tenting, due to inaccessible water and call light. Despite informing the DON, the resident's water cup remained out of reach, and she expressed discomfort and pain, indicating a deficiency in providing necessary hydration and assistance.
A resident with heart and kidney failure, receiving hospice services, fell and sustained a forehead laceration. Care plan changes were made, and the responsible party and physician were notified, but the hospice service was not informed, violating the facility's hospice agreement.
The facility failed to post necessary signage and ensure proper use of PPE for two residents on Enhanced Barrier and Transmission Based Precautions. One resident with a urinary catheter had no EBP signage, and an LPN did not use a gown during care, contaminating supplies. Another resident tested positive for COVID-19, but there was no TBP signage, leaving staff unaware of required precautions.
A resident with severe cognitive impairment experienced a persistent urine odor in their bathroom due to maintenance issues. Despite routine cleaning, the odor persisted, with staff noting worn caulking and a potentially faulty wax ring around the toilet. The Nursing Home Administrator acknowledged the problem, identifying the bathroom as the source of the odor.
A facility failed to maintain accurate medical records for a resident with legal blindness and uropathy. Despite a physician's recommendation for a urinalysis due to catheter pain and red drainage, there was no documentation of a urine sample being collected. The RN could not recall details of the incident, and the DON did not document a decision made with the Medical Director regarding testing criteria.
The facility failed to ensure a qualified Infection Preventionist (IP) was present during a COVID-19 outbreak. The DON, who was certified as an IP, was on leave, and the NHA and an uncertified RN assumed IP duties. Three residents tested positive for COVID-19, and documentation was incomplete and inconsistent. The certified regional IP did not attend QA meetings during the DON's absence.
Failure to Recognize and Respond to Acute Change in Condition for a Full-Code Hospice Resident
Penalty
Summary
Failure to recognize, assess, and respond to an acute change in condition occurred for one cognitively intact resident who was a full code and on hospice services. The resident had diagnoses including dementia, psychotic disturbance, anxiety, and insomnia, and an MDS BIMS score of 13 indicating intact cognition. Documentation showed that the resident’s code status remained full code per the admission record, hospice plan of care, and care conferences. A progress note documented that hospice was called when the resident was nonresponsive, with vital signs recorded at that time, and hospice indicated that if the resident needed to be sent to the hospital due to coding, the facility could do so. Over the following days, multiple progress notes described the resident as very lethargic, difficult to arouse, and later not responsive, with poor or no oral intake and very little fluid intake due to inability to swallow. Staff documented shallow respirations, mouth breathing, and that the resident appeared to be actively dying, with an inability to obtain a blood pressure and a respiratory rate of 40. Notes also showed attempts to contact the resident’s son regarding code status and declining condition, with hospice being notified and acknowledging the full code status and the need to send the resident out if required. Despite these documented changes, there was no evidence in the EMR of acute assessments or systematic acute monitoring in response to the resident’s declining condition. Vital sign records showed that vital signs were obtained only five times over a 14‑day period, and no additional vital signs or acute assessments were documented during the period of decline. The resident remained unresponsive with continued decline until transfer to the hospital, where she was found in respiratory failure, intubated, and diagnosed with right lower lobe pneumonia, COVID‑19 infection, severe acidosis, hyperkalemia, and septic shock. In interview, the DON acknowledged being unable to locate documentation of an acute assessment or acute monitoring for the change in condition and stated that the resident was unresponsive with continued decline until transfer, and that there should have been acute documentation and a transfer sooner. Facility policy required prompt notification of the resident, physician, and representative of changes in condition and transfer to the hospital when necessary, but the documentation did not show that this was carried out in a timely, acute response to the resident’s change in condition.
Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions and Supervision
Penalty
Summary
A resident with a history of major depressive disorder, major neurocognitive disorder due to Alzheimer's disease, and psychotic mood disorder was admitted to the facility and exhibited escalating aggressive and disruptive behaviors. Documentation shows that the resident became physically and verbally abusive towards staff and other residents, including making threats of physical harm, entering other residents' rooms, and taking their belongings. Despite repeated incidents of aggression, including physical assaults on staff and threats to other residents, the care plan was not updated in a timely manner to address these behaviors, and enhanced supervision or monitoring was not implemented. The facility failed to notify the interdisciplinary team (IDT) or provider of the resident's escalating behaviors and did not conduct behavior management evaluations or update interventions in response to the resident's aggression. There was also a lack of documentation regarding IDT meetings or behavioral management discussions, and the care plan was not revised to reflect new or worsening behaviors until after the resident was transferred to the hospital. Additionally, the facility did not report or investigate an allegation of resident-to-resident physical abuse, nor did it document provider notification or assessment following incidents of aggression and ineffective medication administration. Another resident was physically assaulted by the aggressive resident, resulting in tenderness to the jaw and the need for non-pharmacologic pain relief. The facility's own investigation confirmed physical contact occurred. The facility's policies required ongoing assessment, care planning, and monitoring for residents with behaviors that might lead to conflict or abuse, but these were not followed. The failure to implement timely interventions, update care plans, and notify appropriate staff and providers contributed to the deficiency in protecting residents from abuse.
Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of resident-to-resident physical abuse was not reported or investigated. A female resident with major depressive disorder and major neurocognitive disorder due to Alzheimer's disease, who had a history of physical aggression toward staff, was alleged to have hit her roommate on the left hand. The incident was documented in a progress note by a registered nurse, but there was no evidence that the allegation was reported to the abuse coordinator as required by facility policy. The nurse assessed the resident and found no injury, and believed the interaction was playful based on the residents' relationship, but did not document all details in the chart or initiate the required reporting process. Interviews revealed that the nursing home administrator was not made aware of the allegation, and staff did not follow the policy for immediate reporting of abuse allegations. The facility's written policy requires all alleged violations to be reported to the administrator and investigated, but this process was not followed in this case. The failure to report and investigate the allegation resulted in noncompliance with the facility's abuse prevention and response procedures.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with a history of rolling out of bed. The resident, who had diagnoses including autism, anxiety, and developmental disorder, was care planned to have a fall mat on the left side of the bed, the bed kept in the lowest position when not providing care, and frequently used items including the call light within reach. Despite these interventions, a CNA left the resident unattended with the bed raised to hip level while retrieving a lift, during which time the resident rolled off the bed and sustained a femur fracture. The resident's care plan and facility policy required supervision and specific interventions to minimize fall risk, but these were not followed at the time of the incident. Observations and interviews confirmed that the call light was not within the resident's reach, contrary to care plan directives. The CNA involved acknowledged leaving the bedside with the bed elevated, and the Nursing Home Administrator confirmed the resident's history of rolling out of bed. Facility documentation and staff interviews further substantiated that the required fall prevention measures were not consistently implemented, directly leading to the resident's fall and injury.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who was admitted with diagnoses including autism, anxiety, and a gastrostomy requiring tube feedings. The resident's care plan and physician's orders indicated the need for EBP, and facility policy required gown and gloves to be available and used during high-contact care activities, such as incontinence care, for residents on EBP. During an observation, two certified nursing assistants provided incontinence care to the resident without wearing gowns, despite signage on the door indicating EBP was required. Interviews with the staff involved revealed a lack of awareness and understanding regarding the application of EBP. One CNA was not aware that the resident required EBP and believed that EBP was only necessary for care related to the tube feeding, not incontinence care. A registered nurse also stated that EBP was not required for CNAs since they did not handle the tube feeding. However, facility signage and policy defined high-contact care activities, such as incontinence care and transfers, as requiring gown and gloves for residents on EBP.
Failure to Provide Timely Assessment and Pain Management After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer's disease experienced a fall resulting in a fractured hip. Following the fall, the resident exhibited clear signs of severe pain, inability to bear weight, and abnormal alignment of the right leg. Despite these symptoms, the facility did not promptly initiate emergency medical treatment or appropriate mobility interventions for a potential hip fracture. The resident was placed in a recliner rather than being immobilized, and the care plan was not updated to reflect the new risk factors or interventions needed for pain and immobility. Pain assessments and management were inadequate. Only one pain assessment was documented from the time of the fall until 6 PM, with a pain rating of 10/10, and only one additional assessment was recorded overnight, with a pain rating of 8/10. The only pain medication administered was acetaminophen, which was documented as non-effective for the resident's severe pain. No other pain relief measures were provided, and the resident continued to experience excruciating pain until transfer to the hospital the following morning. The facility also failed to ensure timely diagnostic evaluation, as the x-ray ordered after the fall was not completed before the resident's transfer to the hospital. Upon arrival at the emergency department, the resident was found to have a comminuted, displaced, and angulated hip fracture, and surgery was scheduled. The emergency room physician noted the lack of immediate transfer to the hospital despite the resident's severe pain and significant injury. Documentation inconsistencies were also noted regarding whether the fall was witnessed and the care provided post-fall.
Improper Storage and Monitoring of Insulin
Penalty
Summary
The facility failed to properly monitor and store medications, specifically insulin, in the medication room refrigerator. During an observation, a vial of Novolin N insulin was found, which had been opened and placed in service on 9/1/24, despite being discontinued and should have been discarded. The Doctor's Orders indicated that Humulin N was ordered for the resident on 8/31/24 and discontinued on 9/2/24. The manufacturer's package insert for Novolin N specifies that opened vials should be kept at room temperature and discarded after 6 weeks of use. The facility's policy on medication storage, last reviewed on 9/27/23, mandates that all medications be stored according to the manufacturer's recommendations. The presence of outdated and discontinued insulin in the medication room refrigerator indicates a failure to adhere to these guidelines, posing a risk of administering outdated medication to residents.
Infection Control Deficiencies in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to maintain proper infection control procedures for residents in isolation for COVID-19, potentially affecting 14 of 51 residents. Observations revealed that room doors for residents under Airborne Contact Precautions were left open, contrary to the signage indicating that doors should remain closed to maintain negative pressure. This was observed in the rooms of three residents, all of whom tested positive for COVID-19. The Director of Nursing (DON) stated that leaving doors open was permissible to reduce the trauma of isolation, despite the potential risk of virus transmission. Staff were observed not adhering to the required personal protective equipment (PPE) protocols. In one instance, a certified nursing assistant (CNA) was seen exiting a resident's room wearing a surgical mask under an N95 respirator, which is against the guidelines as it prevents the N95 from properly sealing. Another CNA was observed exiting a room without wearing the required eye protection, acknowledging the oversight only after leaving the room. Additionally, a laundry staff member entered a COVID-19 isolation room wearing only a surgical mask, without the necessary PPE such as an N95 mask, gown, gloves, and eye protection. The facility's COVID-19 Prevention, Response, and Reporting policy requires healthcare personnel to adhere to standard precautions and use appropriate PPE, including an N95 respirator, gown, gloves, and eye protection when entering the room of a resident with COVID-19. However, multiple staff members failed to comply with these protocols, as evidenced by the observations and interviews conducted during the survey. The DON acknowledged the requirement for all staff to wear the necessary PPE when in any COVID-19 room, yet lapses in adherence were evident.
Inadequate Hydration and Assistance for Resident
Penalty
Summary
The facility failed to ensure adequate and accessible hydration for a resident, identified as R206, who was admitted with heart and kidney failure and was under hospice care. Observations revealed that R206 was frequently found in bed with dry and peeling lips, a dry tongue, and signs of dehydration such as skin tenting. Despite these observations, the resident's water cup was consistently placed out of reach, and the call light button was also inaccessible, preventing the resident from requesting assistance. The resident expressed discomfort, stating she felt cold, terrible, and had a dry mouth, which hindered her ability to speak. The Director of Nursing (DON) was informed of the resident's condition and the inaccessibility of water, yet subsequent observations showed no change in the situation. The resident continued to be found with her water cup out of reach, and no moisture swabs were available in the room. The resident was observed asking for help and pain relief, indicating ongoing distress and unmet needs. These findings highlight a deficiency in the facility's provision of necessary hydration and assistance to the resident, contributing to her discomfort and potential health risks.
Failure to Notify Hospice of Care Plan Changes After Resident Fall
Penalty
Summary
The facility failed to notify the hospice service of a change in the plan of care for a resident, identified as R206, after the resident experienced a fall. R206 was admitted to the facility with diagnoses including heart and kidney failure and began hospice services shortly after admission. On January 8, 2025, R206 was observed with a large dressing on her forehead, having sustained a laceration from a fall earlier that day. The medical record indicated that care plan changes were made following the fall, and the responsible party and physician were notified. However, the documentation did not reflect that the hospice service was informed of the fall and the subsequent changes to the care plan, as required by the facility's hospice agreement. An interview with RN G confirmed that while the physician and responsible party were contacted, the hospice service was not notified of the care plan changes.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to ensure proper posting of Enhanced Barrier Precaution (EBP) and Transmission Based Precaution (TBP) signage, proper use of Personal Protective Equipment (PPE), and prevention of contamination of treatment supplies and the treatment cart for two residents. Resident #33, who was admitted with diagnoses including legal blindness and obstructive and reflux uropathy, had an active order for EBPs due to a urinary catheter. However, there was no EBP or PPE instruction signage on Resident #33's door, and staff were unaware of the need for these precautions. During a procedure, an LPN did not use a gown as required and contaminated treatment supplies by carrying them without proper precautions. Resident #394, admitted with post-procedural complications and neoplasm of the pancreas, tested positive for COVID-19 and was placed on TBPs. Despite this, there was no signage on Resident #394's door indicating the need for TBPs or PPE, leading to staff being unaware of the precautions required. The Director of Nursing acknowledged the oversight in placing the necessary signage. The facility's policies on EBPs and TBPs were not followed, resulting in increased potential for cross-contamination and spread of infection.
Persistent Urine Odor in Resident's Bathroom Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for a resident diagnosed with dementia, who has severe cognitive impairment and requires assistance with all activities of daily living. During an initial tour, a strong urine odor was detected in the resident's room, particularly in the bathroom. Certified Nurse Assistants confirmed the persistent odor, noting that the resident often misses the toilet, and despite routine cleaning efforts, the smell remains. Further investigation revealed that the bathroom floor was wet, potentially with urine, and the caulking around the toilet was worn, allowing urine to penetrate gaps. The Maintenance Director suggested that the wax ring might be faulty, contributing to the odor issue. The Nursing Home Administrator acknowledged the problem and identified the bathroom as the source of the odor.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain an accurate health record for a resident, resulting in unclear documentation and potential miscommunication regarding the resident's health care status. The resident, who was admitted with diagnoses including legal blindness and obstructive and reflux uropathy, had a physician communication form indicating concerns about pain related to a Foley catheter and red drainage. The physician recommended a urinalysis, but the electronic medical record lacked documentation of a urine sample being collected or any follow-up on the physician's order. During interviews, the RN involved could not recall how she learned of the resident's complaints and was unsure if the urine sample was collected and sent to the lab. The DON reported discussing the situation with the Medical Director and deciding that the resident did not meet the criteria for urine testing, but this conversation was not documented in the medical record. The facility's policy requires that each resident's medical record accurately represent their experiences and include complete, accurate, and timely documentation, which was not adhered to in this case.
Failure to Ensure Qualified Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was present to properly assess, implement, and manage the Infection Prevention and Control Plan during a COVID-19 outbreak. The Director of Nursing (DON) had attained an IP certificate, but was on leave from 10/7/23 through 12/13/23. During this period, the Nursing Home Administrator (NHA) and a Registered Nurse (RN) without IP certification assumed the IP duties. The NHA acknowledged not meeting the regulatory requirements of an IP, and the RN was not certified as an IP. Despite the availability of a certified regional IP for guidance, there was no record of their attendance at Quality Assurance (QA) meetings during the DON's absence. The DON was unaware of who provided the Infection Control report during her leave. During the DON's leave, three residents tested positive for COVID-19 between 11/13/23 and 11/22/23. The facility's COVID-19 Notification postings and Exposure Checklists were reviewed, revealing inconsistencies in the duration of guidance followed and incomplete documentation. The checklists for the COVID-19 positive residents were unsigned and undated, although the NHA had initialed the individual tasks. This lack of proper documentation and oversight during the COVID-19 outbreak highlights the deficiency in the facility's infection prevention and control program during the DON's absence.
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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