Bayside Village
Inspection history, citations, penalties and survey trends for this long-term care facility in L' Anse, Michigan.
- Location
- 832 Sicotte Street, L' Anse, Michigan 49946
- CMS Provider Number
- 235144
- Inspections on file
- 28
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Bayside Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised for about 30 minutes after staff failed to properly assess elopement risk, did not provide adequate supervision, and did not respond appropriately to exit door alarms. The resident exited through a malfunctioning delayed egress door, was found outside in a ditch with complaints of cold and pain, and required transfer to the ED. Staff were inattentive, did not update care plans or assessments in response to behavioral changes, and did not follow facility policies regarding supervision and alarm response.
A resident with a Foley catheter experienced blood in the urine, swelling, and decreased urine output, with repeated findings of an overfilled catheter bag that was not emptied as required. Staff failed to document care accurately and in a timely manner, and significant changes in the resident's condition were not communicated to the physician. These deficiencies led to the resident developing a ruptured bladder, UTI, and septic shock, ultimately resulting in death.
A resident with moderate cognitive impairment and a history of falls was being assisted in a transfer by a CNA who failed to use a gait belt as required by the care plan and facility policy. Instead, the CNA held the resident by her pants and buttocks, resulting in the resident slipping, falling, and sustaining a head laceration and pelvic fracture. Documentation and interviews confirmed the care plan was not followed, leading to hospitalization for the resident.
A significant medication error occurred when an RN administered medications intended for another resident, due to improper labeling and storage of medication cups. The affected resident, with multiple chronic conditions, received several unprescribed medications and required hospital monitoring for potential adverse effects. Family notification was not documented, and facility policy regarding medication handling was not followed.
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. Interviews revealed that residents experienced delays in receiving medications and assistance, with one resident falling and being left on the floor due to insufficient staff. Staff confirmed frequent understaffing, particularly during night shifts and weekends, which compromised care. The facility's staffing schedule did not meet the requirements outlined in its Facility Assessment.
The facility failed to ensure that three CNAs had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. The CNAs, hired at different times, lacked dated competency skills after their respective hire dates. The DON and NHA acknowledged the absence of dated competency skills, and the Facility Assessment indicated annual evaluations on 23 areas, but the surveyor received an incomplete and undated list of training on 13 areas.
The facility did not conduct annual performance reviews for three CNAs, as required by their policy. CNAs hired in 2021, 2022, and 2023 had not received reviews, confirmed by the DON and HR staff. This lapse was acknowledged by the NHA and DON, indicating non-compliance with the facility's policy.
The facility failed to maintain food safety standards, with staff not washing hands between handling soiled and clean dishes, improper cleaning of cooling collars, and incorrect sanitizer testing. Ice buildup in the freezer and dust on a fan were noted, along with splash contamination risk in the dining room. Staff U did not follow hand hygiene protocols, posing a risk to residents.
The facility failed to ensure the QAPI committee met quarterly with required members, including the Medical Director and DON, leading to potential quality-of-care concerns for all 57 residents. Several meetings lacked attendance by the Medical Director, and no meetings were held in November and December 2023, violating CMS regulations.
The facility failed to provide three CNAs with the required 12 hours of annual in-service training, as confirmed by interviews and record reviews. CNA P, S, and T did not meet the training requirement based on their hire dates, with only 9.5, 5, and 10.25 hours completed, respectively. The facility's policy mandates at least 12 hours of training annually to ensure CNA competence, a requirement acknowledged as unmet by the DON and NHA.
The facility failed to provide behavioral health care training to two CNAs, as required by their policy. The training logs showed no record of such training for these staff members, and the Facility Assessment did not include a requirement for it. The NHA and DON acknowledged this absence, which could potentially affect all 57 residents.
The facility failed to update care plans after multiple falls for several residents, including those with Alzheimer's and Parkinson's disease. Despite falls occurring, care plans were not revised to include new interventions, as acknowledged by the DON. This oversight was contrary to the facility's policies on accident prevention and fall risk assessment.
The facility failed to ensure accurate physician visits and documentation for four residents, leading to potential gaps in comprehensive medical care. Physician K's notes often contained inaccuracies, such as incorrect medication dosages and diagnoses, and lacked thorough reviews of residents' conditions. The facility's policy on physician supervision and documentation was not followed, contributing to these deficiencies.
The facility failed to label opened inhalers and eye drops with the date they were opened, as required by policy. During audits of two medication carts, it was found that several medications for multiple residents were not labeled with opening dates, leading to the potential use of expired medications. Both a registered nurse and an LPN acknowledged the oversight, and the DON confirmed the policy requirement.
A resident with Alzheimer's Disease was observed in a wheelchair with a tray table and pommel cushion, which were used as restraints without proper assessments, physician orders, or care plan documentation. The facility did not provide education on restraint risks to the resident's representative, and no interventions were attempted before applying the restraints. The facility's policy on a restraint-free environment was not followed.
A resident receiving hospice services experienced a lack of proper coordination and communication between the LTC facility and the hospice provider. The facility did not have a physician order for hospice, nor a care plan or documentation of hospice visits in the resident's medical record. Interviews with the DON and an RN revealed uncertainty about the start date of hospice services and a lack of documentation on scheduled hospice visits. The facility's policy on hospice coordination was not followed, leading to this deficiency.
A resident with depression and other medical conditions expressed feelings of depression due to the recent loss of their son. The facility failed to provide supportive visits, grief counseling, or referrals to outside services, and did not include this issue in the resident's care plan. The Social Services Designee and Nursing Home Administrator acknowledged these oversights, which were contrary to the facility's policy on providing medically related social services.
A resident with pressure ulcers did not receive timely wound treatment medication due to the facility's failure to reorder Santyl. Despite physician orders, the medication was unavailable for seven days, and staff did not contact the physician for alternative orders. The facility's policies on medication cross-matching and reordering were not followed, leading to this deficiency.
The facility failed to attempt a gradual dose reduction (GDR) for a resident on Seroquel, despite recommendations, and did not ensure accurate antipsychotic medication dosage for another resident. Discrepancies in medication orders and lack of documentation were noted, with staff unable to explain the incorrect dosage administration.
The facility failed to implement a comprehensive Water Management Plan for Legionella control, as a humidifier used in the resident area was not assessed, and only one water sample was collected annually for testing. The Maintenance Supervisor was unaware of any Legionella discussions during QA or QAPI meetings, and there was no documentation of disinfectant levels or temperature control, exposing residents to potential Legionella infections.
A cognitively impaired resident eloped from the facility after a visitor allowed her to exit. Despite being identified as an elopement risk, the resident did not have a wander alarm due to a history of cutting them off. Staff were unaware of the exit until alerted by another visitor. The facility lacked adequate supervision, especially during weekends, and had no consistent policy for wander guard placement.
Failure to Prevent Resident Elopement Due to Inadequate Assessment, Supervision, and Door Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of progressive neurological disease, diabetes, non-Alzheimer's dementia, anxiety, and depression was not properly assessed for elopement risk, nor adequately supervised, resulting in the resident eloping from the facility undetected for approximately 30 minutes. The resident, who had documented patterns of wandering, was able to exit the building through a 300 Hall door that did not function as intended, opening before the required 15-second delay. Staff failed to notice or respond appropriately to the resident's wandering behaviors, and the resident's care plan did not address wandering or elopement risk until after the incident occurred. Surveillance footage showed the resident wandering unsupervised throughout the facility for an extended period, including multiple attempts to exit the building. Staff were observed to be inattentive, with one LPN using a personal cell phone at the nurses' station and leaving the resident unsupervised. When the exit door alarm was triggered, staff did not conduct a head count or search outside, only resetting the alarm and looking out the window. The resident was later found outside in a ditch, inadequately dressed for the weather, complaining of cold and pain, and required transfer to the emergency department for evaluation. Documentation and interviews revealed that staff did not consistently review progress notes or update elopement risk assessments in response to changes in the resident's behavior. The resident's care plan lacked interventions for wandering prior to the incident, despite multiple documented episodes of nighttime wandering and exit-seeking. Staff were also not fully aware of or did not follow facility policies regarding supervision, response to exit alarms, and use of personal cell phones, contributing to the failure to prevent the elopement.
Removal Plan
- Elopement and Wandering Residents Policy reviewed and updated.
- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement.
- Maintenance director inspected and tested 300 Hall exit door, accompanied by Surveyor.
- Additional education to all staff regarding proper functioning door alarms was initiated via text and in person.
Failure to Provide Proper Catheter Care, Timely Documentation, and Physician Notification Resulting in Resident Harm
Penalty
Summary
The facility failed to provide proper care and treatment for a resident with an indwelling Foley catheter, resulting in significant harm. The resident, who had diagnoses including benign prostatic hyperplasia, urinary retention, and type 2 diabetes, was cognitively intact and admitted with a Foley catheter in place. Over several days, staff observed and documented blood in the resident's brief and at the tip of the penis, swelling in the thigh, decreased urine output, and a distended catheter bag. Despite these findings, there was a lack of timely and accurate documentation, and significant changes in the resident's condition were not communicated to the physician as required by facility policy. Multiple staff interviews revealed that the resident's catheter bag was repeatedly found to be overfilled, sometimes described as the size of a football, and not emptied during overnight shifts. Certified Nurse Aides reported these findings to nursing staff, but there was no evidence of appropriate follow-up or documentation. Additionally, there were instances where staff were instructed to document care tasks that had not been performed, and late entries were made in the medical record up to a month after the events occurred. The facility's Director of Nursing and other staff acknowledged issues with delayed documentation, lack of investigation, and failure to notify the physician of significant changes, including blood in the urine and decreased output. The resident ultimately experienced worsening symptoms, including abdominal pain, vomiting, confusion, and neurological changes, leading to emergency transfer to the hospital. Hospital records confirmed a diagnosis of ruptured bladder, urinary tract infection, and septic shock. The facility lacked effective catheter care policies at the time of the incident, and there was no documentation of required monitoring such as weights and leg measurements, despite physician orders. The cumulative failures in care, documentation, and communication directly contributed to the resident's decline and subsequent death.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Major Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate assistance and use required assistive devices during a transfer, resulting in a resident sustaining a fall with major injury. The resident, who had moderate cognitive impairment, a history of repeated falls, and required partial to moderate assistance with transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA did not use a gait belt as required by the resident's care plan and facility policy, instead holding the resident by her pants and buttocks. The resident slipped and fell, hitting her head on the overbed table and sustaining a laceration and a pelvic fracture. The incident was not witnessed by a nurse, but the CNA involved provided a written statement confirming the lack of gait belt use. The resident's care plan specified the use of a gait belt and limited assistance for transfers, and the facility's policy mandated gait belt use for residents unable to transfer independently. Documentation and interviews confirmed that the plan of care was not followed at the time of the fall. Following the fall, the resident was assessed, treated for a head wound, and sent to the emergency department, where a pelvic fracture was diagnosed. The facility had not conducted monitoring audits of staff compliance with gait belt use after the incident, and the CNA involved was not available for further interview during the survey. The deficiency was directly related to the failure to follow established care plans and safety policies during resident transfers.
Significant Medication Error Due to Improper Medication Administration and Labeling
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another. The error took place after the RN prepared two medication cups for two residents with similar first initials, labeling the cups with only initials. The RN placed one cup in the medication cart drawer while the resident was being assisted by CNAs, then later mistakenly administered the wrong cup to the resident. The nurse realized the error during administration but had already given the medications. The affected resident had a history of heart failure, hypertension, diabetes mellitus, and depression, and was cognitively intact. The resident received eight medications not prescribed to her, including drugs for blood pressure, diabetes, cholesterol, and an antipsychotic. Following the error, the resident was transferred to the emergency department for monitoring due to concerns about potential adverse effects, such as hypotension. The resident reported mild dizziness and dry mouth upon arrival at the hospital, where she was monitored and later discharged back to the facility. The facility's investigation revealed that the nurse did not notify the resident's family about the transfer or the medication error, and there was no documentation showing that the resident was asked about family notification. Additionally, the facility's policy prohibits saving medication cups in the medication cart, and the nurse's method of labeling contributed to the error. No audits or monitoring of medication administration were conducted following the incident, and only the involved nurse received education regarding the error.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by interviews and record reviews. Four residents, along with three residents from a confidential resident council meeting, reported issues related to insufficient staffing. One resident fell and was left on the floor for an extended period due to a lack of available staff. Another resident experienced delays of up to three hours in receiving medications and having call lights answered. Additional residents and their representatives confirmed that the facility was short-staffed, leading to unmet care needs. Interviews with facility staff, including the Director of Nursing, Nursing Home Administrator, LPNs, and CNAs, corroborated the residents' concerns. The Nursing Home Administrator acknowledged that there were 11 open nursing positions. Staff members reported frequent understaffing, particularly during the night shift and weekends, which resulted in care being compromised. The facility's staffing schedule did not align with its Facility Assessment, which indicated a need for more CNAs than were actually scheduled during certain shifts.
Deficient Competency Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nurse Aides (CNAs) had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. CNA P, hired on February 25, 2022, did not have dated competency skills since the date of hire. CNA S, hired on April 13, 2021, also lacked dated competency skills after the date of hire. Similarly, CNA T, hired on May 27, 2023, did not have dated competency skills after the date of hire. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the absence of dated competency skills for staff, with the DON admitting that the skills training should have been dated. The Facility Assessment, last revised on August 8, 2023, indicated that employees are evaluated annually on 23 areas regarding resident care and facility duties. However, the surveyor did not receive a checklist of these 23 areas, and the facility presented an incomplete and undated list of training on 13 areas, which the DON referenced as the staff's competency training.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nurse Aides (CNAs), identified as P, S, and T, which is a requirement according to their policy. CNA S was hired on April 13, 2021, CNA T on May 27, 2023, and CNA P on February 25, 2022, yet none had received a performance review since their hiring. Interviews with the Director of Nursing (DON) and Human Resource staff confirmed that no performance reviews had been conducted since 2022. This oversight was acknowledged by both the Nursing Home Administrator and the DON, indicating a lapse in adherence to the facility's policy that mandates annual reviews to ensure adequate care and meet resident needs.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Dietary Aide E was seen handling soiled dishes and then clean dishes without washing hands in between, violating the FDA Food Code 2017, which mandates handwashing after handling soiled equipment. Additionally, blue cooling collars used by staff were improperly cleaned, as they were only wiped down with a quaternary solution instead of being immersed, potentially leading to contamination. Further observations revealed that the concentration of sanitizer in wiping cloth buckets was not properly tested, as Kitchen Manager D did not follow the correct procedure for using test strips, resulting in an inaccurate reading. The walk-in freezer had significant ice buildup due to damaged door seals, and a fan near the dish machine was dusty, both of which are against FDA guidelines for maintaining clean and well-repaired equipment and facilities. In the dining room, the placement of a hand sink led to clean plates being exposed to splash contamination. Staff U was observed not performing hand hygiene after touching their scalp, facial hair, and clothing before handling food and utensils, contrary to the facility's hand hygiene policy. These actions and inactions collectively posed a risk of foodborne illness to the 57 residents in the facility.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, as mandated by CMS regulations. The review of attendance documentation revealed that the Medical Director or their designee did not attend several meetings, including those held on 4/30/2024, 7/13/2024, 8/10/2023, 1/19/2024, 2/2/2024, 3/21/2024, 4/11/2024, and 5/9/2024. Additionally, no meetings were held in November and December of 2023, and no attendance records were found for these months. The Director of Nursing (DON) was also absent from the meeting on 1/19/2024 and 5/9/2024. The Nursing Home Administrator (NHA) acknowledged the absence of required QAPI committee members during each quarter, which is a violation of the regulation. During an interview, the NHA mentioned that the Medical Director, referred to as Physician K, only received payment for dictation provided for resident care and did not want payment for serving as the Medical Director. The facility's QAPI plan policy, which should detail the required committee member attendance per CMS regulation, was not provided by the survey exit. The absence of the Medical Director and other key members from the QAPI meetings resulted in the potential for quality-of-care concerns for all 57 residents in the facility.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of annual in-service training. This deficiency was identified during interviews and record reviews. Human Resource Staff O confirmed that the annual training requirement is based on each CNA's hire date. However, CNA P, hired on February 25, 2022, had only completed 9.5 hours of training. CNA S, hired on April 13, 2021, had completed only 5 hours, and CNA T, hired on May 27, 2023, had completed 10.25 hours. The facility's policy and Facility Assessment both stipulate that CNAs must receive at least 12 hours of training annually to ensure their continuing competence. The Director of Nursing and Nursing Home Administrator acknowledged the failure to meet this requirement, which potentially affects the care needs of all 57 residents in the facility.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that behavioral health care training was provided to two of three staff members reviewed for this requirement. Specifically, Certified Nurse Aide (CNA) T, hired on May 27, 2023, and CNA S, hired on April 13, 2021, had no record of receiving behavioral health care training according to the [Vendor] computer training logs reviewed on July 10, 2024. The facility's policy on the Nurse Aide Training Program, implemented on April 11, 2024, mandates that in-service training should be provided by qualified personnel and should include behavioral health care training based on the special needs of the residents. However, the Facility Assessment did not include a requirement for behavioral health training for staff. During an interview on July 11, 2024, the Nursing Home Administrator and Director of Nursing acknowledged the absence of behavioral health training. This deficiency had the potential to result in unmet behavioral health care needs for all 57 residents in the facility.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise care plans after multiple falls for four residents, which resulted in the potential for further falls and injury. Resident #17, who had diagnoses including unsteadiness on feet and schizophrenia, experienced four falls between January and March, yet their care plan was not updated after any of these incidents. The Director of Nursing (DON) acknowledged that revisions should occur after each fall but admitted to sometimes lacking interventions to add. Similarly, Resident #47, with diagnoses including Parkinson's disease and hypertension, had a fall in July, but their care plan was not revised post-fall. The DON admitted to issues with person-centered care plans. Resident #26, diagnosed with Alzheimer's Disease and severely cognitively impaired, experienced multiple falls from May to July, but their care plan was not updated with new interventions to prevent recurrence. Resident #36, also with Alzheimer's Disease, had falls in February and April, yet their care plan did not include the use of a wheelchair tray table, which was used as a fall prevention measure. The facility's policy on accidents and supervision, as well as fall risk assessment, emphasized the need for implementing and modifying interventions to prevent accidents, which was not adhered to in these cases.
Deficient Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that physician visits accurately reviewed the total program of care for four residents, resulting in a potential lack of comprehensive and supervised medical care. The physician, identified as Physician K, did not conduct thorough reviews of the residents' medical conditions and medications during their visits. For Resident R24, the physician's notes over several months indicated the continuation of medications that had been discontinued, and the physician admitted to not verifying the accuracy of the medication information provided by the facility. Resident R26's records showed a lack of physician visit documentation after April, despite being due for a visit in June. The Health Information Coordinator (HIC) acknowledged the absence of documentation and intended to follow up with the hospital physician practice. Additionally, the physician's notes for Resident R26 included incorrect medication dosages and lacked a comprehensive review of the resident's condition. For Resident R36, the physician's notes included incorrect diagnoses and medication dosages, and there was no documentation of a comprehensive review of the resident's systems and medications. Similarly, Resident R38's records showed discrepancies in diagnoses and a lack of follow-up on a documented pressure ulcer. The Nursing Home Administrator was aware of the concerns with the physician's documentation but had not addressed them effectively. The facility's policy required physicians to actively supervise residents and document comprehensive progress notes, which was not adhered to in these cases.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to ensure that inhalers and eye drops were labeled with the dates when they were opened, as per the facility's policy. During an audit of the 100-hall medication cart, it was observed that five bottles of opened eye drops for four different residents were not labeled with the date they were opened. Additionally, three opened inhalers for two different residents were also not labeled with the date they were opened. One of these inhalers was found in a clear plastic bag with a pharmacy label indicating it was dispensed on 5/30/24, and a registered nurse confirmed that it was expired as inhalers are considered good for six weeks after opening. Similarly, an audit of the 300-hall medication cart revealed two opened eye drop bottles for one resident and four opened inhalers for two different residents, none of which were labeled with the date they were opened. Both the registered nurse and the licensed practical nurse involved acknowledged that the medications should have been labeled with the date when opened. The Director of Nursing confirmed that the facility's policy requires eye drops and inhalers to be labeled with the date they are opened, as their discard dates are based on this information rather than the expiration dates.
Failure to Ensure Proper Use and Documentation of Restraints
Penalty
Summary
The facility failed to ensure that appropriate assessments, physician orders, risk education, medical justification, and care plans for restraints were in place for a resident with Alzheimer's Disease. The resident was observed sitting in a wheelchair with a tray table attached, which secured her in the wheelchair, and a pommel cushion. There was no documentation in the care plan for the use of these restraints, and the Minimum Data Set (MDS) did not code the use of physical restraints. The facility did not have physician's orders for the tray table or pommel cushion, and the Director of Nursing (DON) confirmed that no restraint assessments or education on the risks of restraint usage had been provided to the resident's representative. The DON provided a sheet of paper with a note from the resident's daughter requesting the use of a tray table for safety and positioning, but there was no evidence of a formal consent process or discussion of potential risks. The DON admitted that no interventions had been attempted prior to applying the restraints and that the Occupational Therapist (OT) and Physical Therapist Assistant (PTA) had no information on the restraints. The facility's policy on a restraint-free environment was not followed, as there was no determination of a specific medical symptom requiring the use of restraints, nor was the care plan updated to address risks related to restraint use.
Failure in Hospice Care Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, initially admitted for skilled therapy, experienced a severe health decline and began receiving hospice care. However, the facility did not have a physician order for hospice in the resident's medical record, nor was there a care plan for hospice services. Additionally, hospice visit notes and documentation were missing from the resident's medical record. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the hospice documentation was expected to be in a binder at the nurses' station or in the resident's room, but upon review, the binder lacked the necessary hospice documentation. The DON and RN were uncertain about the exact start date of hospice services for the resident, and there was no clear coordination of care plans between the facility and hospice. The RN mentioned that hospice would call on the day of their visits, but there was no documentation on staffing sheets regarding scheduled hospice visits. Hospice documentation received later indicated that the resident started hospice services on a specific date, but the hospice certification and plan of care lacked a physician's signature or date. The facility's policy on coordination of hospice services emphasized the need for communication and a coordinated care plan, which was not adhered to in this case.
Failure to Provide Adequate Social Services for Grieving Resident
Penalty
Summary
The facility failed to provide adequate medically related social services to a resident, identified as Resident #15, who was reviewed for social services care. The resident had been admitted to the facility with diagnoses including depression, heart failure, hypertension, and diabetes mellitus. Despite having intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, the resident expressed feelings of depression related to the recent loss of their son, who had cerebral palsy. The resident reported that the staff or social worker did not engage in discussions about this loss. The Social Services Designee (SSD) acknowledged that no supportive services or emotional support were provided to the resident regarding the loss of their son. The SSD admitted to not discussing grief counseling or offering outside agency support to the resident, nor was there any inclusion of this issue in the resident's care plan. The Nursing Home Administrator confirmed these oversights, noting that the SSD did not address the loss, implement a care plan, or offer support or outside services during the most recent assessment. The facility's policy on social services, which mandates the provision of medically related social services to maintain residents' well-being, was not adhered to in this case.
Failure to Provide Timely Wound Treatment Medication
Penalty
Summary
The facility failed to ensure the timely reorder and acquisition of Santyl, a wound treatment medication, for a resident with pressure ulcers. The resident, who had a history of partial traumatic amputation of the right great toe, required Santyl for multiple wound sites as per physician orders. However, from July 3rd to July 9th, the medication was unavailable, and there was no documentation of any attempt to contact the physician for a change in orders. During interviews, the RN and LPN involved in the resident's care confirmed the unavailability of Santyl and acknowledged that no action was taken to address the issue. The RN was unaware of the reason for the medication's absence, and the LPN did not inquire about the missing medication or document any communication with the physician. The Director of Nursing confirmed the lack of Santyl and the absence of any documented attempts to resolve the issue. The facility's policies on medication cross-matching and reordering were not followed, as evidenced by the failure to reorder Santyl when it was running low. The Medication Cross Match policy required a weekly check to ensure sufficient medication supply, and the Medication Reordering policy mandated reordering when doses were low. These policies were not adhered to, resulting in the resident going without the prescribed wound treatment medication for seven days.
Failure to Attempt GDR and Ensure Accurate Medication Dosage
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed psychotropic medications, specifically Seroquel, despite a recommendation for GDR in the psychological assessment. The resident, who was admitted with diagnoses including Alzheimer's disease, psychotic disorder with delusions, and depression, had no documented evidence of acceptance or declination of the GDR recommendation for Seroquel. Interviews with facility staff confirmed that no GDR was completed in the last year, and no clinical rationale for the lack of an attempted dose reduction was provided. Additionally, the facility failed to ensure accurate antipsychotic medication dosage for another resident, who was observed with abnormal involuntary facial movements suggestive of antipsychotic medication use. The resident's medication orders included an antipsychotic dosed at 3 mg twice daily, which was not signed by a physician. Discrepancies were found between the physician's documentation, psychiatric service provider's notes, and the current medication order, with no recommendations from the consultant pharmacist regarding the antipsychotic medication. Interviews with facility staff, including the social services designee and nurse manager, revealed a lack of documentation for physician visits and medication orders. The facility's administrator and director of nursing were unable to explain the discrepancy in the antipsychotic medication dosage, and no information was found to justify the administration of 3 mg twice daily instead of the documented 2 mg twice daily.
Failure to Implement Comprehensive Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to develop and implement a comprehensive Water Management Plan (WMP) for controlling Legionella in its potable water supply system. During an inspection, it was observed that a humidifier in the boiler room was used to aerosolize potable water into the resident area, but this device had not been assessed for Legionella control. The Maintenance Supervisor (MS) admitted that the facility only collected one water sample per year for Legionella testing, which is insufficient according to the facility's own WMP guidelines. The WMP outlined specific control measures, including temperature management and disinfectant level control, but these were not being documented or monitored effectively. Further interviews revealed that the Maintenance Supervisor was unaware of any discussions regarding Legionella during the facility's Quality Assurance (QA) or Quality Assurance and Performance Improvement (QAPI) meetings. The facility's WMP required regular monitoring and reporting of water management activities, but there was no documentation of disinfectant levels, temperature control, or risk assessments related to the humidifier. This lack of documentation and oversight indicates a significant gap in the facility's infection prevention and control program, potentially exposing all 57 residents to the risk of Legionella-related respiratory infections.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a cognitively impaired resident. The incident occurred when a visitor entered the building and allowed the resident to exit. The resident, who had severe cognitive impairment and a history of wandering, was found at a nearby gas station and returned to the facility by a former employee who recognized her. Staff were unaware of the resident's exit until alerted by another visitor who had taken a photograph of the resident at the gas station. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of wandering behavior. Despite being identified as an elopement risk, the resident did not have a wander/elopement alarm due to a history of cutting off the alarms. The facility's Elopement Risk binder included the resident's information, but there was no consistent process or policy for determining the placement of wander guards on residents at risk of elopement. Interviews with staff and family members revealed that the facility lacked adequate supervision, especially during weekends when staffing levels were lower. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and person-centered care plans, but these measures were not effectively implemented. Surveillance video confirmed that no staff were present near the entrance doors when the resident exited the building.
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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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