Caretel Inns Of Linden
Inspection history, citations, penalties and survey trends for this long-term care facility in Linden, Michigan.
- Location
- 202 South Bridge Street, Linden, Michigan 48451
- CMS Provider Number
- 235646
- Inspections on file
- 25
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Caretel Inns Of Linden during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions sustained a painful right-hand skin tear in the dining room when another resident with dementia and documented combative behaviors pushed the wheelchair and forcefully grabbed the resident’s hand. Staff did not witness the incident and only responded after the injured resident called for help or was seen bleeding. The injured resident later reported feeling unsafe and confined herself to her room. The aggressor’s behavior care plan already noted combative behavior, wandering, and hitting at others, but contained only a general intervention for positive interaction and was not revised with specific measures to manage his combativeness or protect other residents after the altercation.
A resident with pain and hemiplegia experienced significant medication errors when scheduled Cyclobenzaprine (Flexeril) doses were missed because the drug was unavailable, and nursing staff did not notify the physician or obtain an alternative despite a standing order for around‑the‑clock pain management. Pharmacy records showed a 30‑day supply should have remained in use, with multiple days of doses unaccounted for, and the medication was not stocked in the backup box. During the same period, a Fentanyl patch dated several weeks earlier was found still applied to the resident’s chest even though the order for the patch had been discontinued, and the DON was unaware it remained in place. These events occurred despite facility and pharmacy policies requiring medications to be administered as ordered and procedures to address unavailable or delayed medications.
The facility failed to provide a clean and homelike environment for two residents, resulting in unclean rooms and bathrooms, and a lack of clean linens. One resident's room was cluttered with bags of clothes and towels, and both residents' bathrooms had significant staining and cleanliness issues. The facility also lacked sufficient clean towels and washcloths, and was unable to provide housekeeping and linen policies when requested.
A resident with urinary retention experienced severe abdominal pain due to the facility's failure to maintain a functional bladder scanner. The scanner was inoperable, and staff were unaware of its condition, leading to complications during a trial void order. Attempts to reinsert a Foley catheter were unsuccessful, resulting in the resident being sent to the ER. The facility's policies on equipment maintenance were not followed, as no repairs or replacements were made for the broken scanner.
A resident with severe cognitive impairment and receiving hospice services developed four facility-acquired pressure ulcers due to the facility's failure to consistently implement preventive interventions. Despite having a care plan that included an air mattress and positioning aids, the resident was often observed without these measures in place. An LPN acknowledged the presence of new pressure ulcers and stated that interventions were in place, but the ulcers still developed. The facility's policy on skin management was not fully adhered to, contributing to the deficiency.
The facility failed to ensure that three CNAs completed the required 12.0 hours of annual competency training. CNA N's records lacked quantified hours and competency assessments, CNA P's records showed only 7.58 hours of training, and CNA O had no written record of completed in-service hours. The HR Director confirmed the absence of an electronic system to track training hours.
The facility failed to secure medication carts and ensure proper labeling and storage of medications. Unattended and unlocked carts were observed, with medications lacking proper labeling and topical treatments stored with oral medications. Staff acknowledged these lapses, which contravened facility policies.
The facility failed to treat residents with dignity, as call lights were not answered promptly, leading to soiled briefs and frustration. Staff were observed using personal phones during care, and grievances were not adequately addressed. Specific cases included a resident with a call light out of reach and another left in discomfort due to delayed assistance.
The facility failed to ensure a safe and sanitary environment, with an open furnace door in a resident's room and multiple sanitation issues in the kitchen, including stagnated water, sewage odors, and a water leak. The maintenance director was unaware of these issues, and no maintenance logs were available.
The facility failed to create timely, person-centered care plans for two residents within 48 hours of admission, leading to inadequate dietary management. One resident with cancer and respiratory issues struggled with chewing and required a different diet, while another with diabetes and chronic kidney disease had unmet dietary needs despite having a dialysis care plan. These care plans were delayed by four and six days, respectively, leaving staff without necessary guidance.
A resident with obstructive sleep apnea did not have a comprehensive care plan for their CPAP machine, leading to improper maintenance. The resident reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The MDS Program Director acknowledged the oversight, which was contrary to facility policy requiring individualized care plans.
A resident with limited range of motion did not receive a restorative nursing program after being discharged from therapy, despite being a good candidate. The resident's medical record lacked documentation of a restorative plan, and the facility's Director of Nursing confirmed the absence of a restorative team. Efforts to train CNAs as restorative aides were ongoing but incomplete. The facility's policy required initiation of restorative programs post-therapy discharge, but this was not followed.
The facility failed to properly store, clean, and label respiratory equipment for residents, leading to potential health risks. A resident with sleep apnea reported that their CPAP mask and tubing had not been changed, and there was no documentation of cleaning. Another resident's nebulizer was improperly stored with moisture remaining, and a third resident's oxygen tubing was not labeled or dated. The facility's policies on equipment maintenance were not followed.
A facility failed to ensure complete documentation and assessment for a resident requiring dialysis. The resident, with a right-sided permacath, had inaccurate records and care plans that did not reflect the correct dialysis access site or provide proper monitoring instructions. The Hemodialysis Communication Forms lacked necessary information about the access site, and the facility's policy did not address permacath care, focusing instead on fistulas. Interviews with the DON and RN Unit Manager revealed they were unaware of these omissions.
The facility failed to ensure daily clinical staff postings were completed and available for review from January to August 2024. The DON stated that the Staffing Report, detailing the number of RNs, LPNs, and CNAs, was to be posted daily. However, reports for July 2024 were mostly missing, and several from January and February 2024 were incomplete. The Scheduler started the forms but relied on others for completion, leading to discrepancies. The receptionist was unaware of her role in this process, resulting in missing and incomplete staffing reports.
A facility failed to obtain informed consent for an antipsychotic medication prescribed to a resident with Alzheimer's dementia and other conditions. The resident's record contained an incomplete psychiatric consultation from a previous admission, lacking specific medication consent. This oversight violated the facility's policy requiring informed consent for psychotropic medications.
A resident with severe cognitive loss was sexually abused by another resident with moderate cognitive impairment. Despite a history of wandering and inappropriate behavior, there were no care plans or physician orders to address the behavior. The facility's intervention of hourly checks was ineffective, and documentation failed to reflect the resident's behavior, contributing to the incident.
A resident experienced a fall and subsequent spinal injury, but the facility failed to retain complete documentation and conduct a thorough investigation. The incident report was incomplete, lacking critical information, and the facility's investigation did not include necessary interviews or documentation to support conclusions. The Director of Nursing and Administrator acknowledged the deficiencies in the investigation and documentation process.
Two residents experienced delays in nutritional assessments and care planning, with inconsistent documentation of meal intake. One resident had difficulty chewing, and the other required dialysis, increasing nutritional risk. The facility failed to address these needs promptly, leading to deficiencies in care.
A facility failed to follow physician's orders and policy for enteral feeding for a resident with severe cognitive impairment, resulting in the resident not receiving the prescribed amount of feeding. The feeding was administered at a lower rate than ordered, and there was no documentation of the total intake. The DON acknowledged the rate was reduced due to nausea but lacked a system for documenting intake when adjustments were made.
A resident with lung cancer and metastasis experienced unrelieved pain due to the facility's failure to promptly assess and manage pain effectively. The resident's family reported ineffective pain medication and delays in processing new orders. The resident was given Tylenol, which did not alleviate the pain, and later received Morphine and Lorazepam simultaneously, which was too sedating. The care plan was delayed, and the facility did not adhere to its policy on resident rights.
Two residents in an LTC facility did not receive their prescribed medications due to unavailability. A Lidocaine Patch and Lantus insulin were not administered as ordered, resulting in a medication error rate of 6.25%. The facility's policy requires timely administration, but the medications were not in stock or delivered on time.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. Two residents did not receive their prescribed medications due to unavailability: one missed a Lidocaine patch, and the other missed a Lantus insulin injection. The nurse and DON were aware of the issues, which were attributed to stock shortages and recent admission delays.
A resident in an LTC facility did not receive their prescribed Lantus insulin due to unavailability, and there was a route error in the insulin order. Additionally, the resident's pain level was not assessed before administering Tylenol, despite an active order for Norco for severe pain. The DON acknowledged the medication unavailability due to the recent admission.
A facility failed to ensure proper documentation of hospice services for a resident with severe cognitive impairment, resulting in missing progress notes in the medical record. Despite being admitted to hospice care months earlier, the most recent note was from over two months prior. Staff interviews revealed that the hospice company was new to the facility and had not been sending updates as frequently as expected.
Failure to Protect Resident From Abuse and Inadequate Behavior Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the dining room. On the date of the incident, a female resident seated in her wheelchair in the dining room was approached by another resident who began pushing her wheelchair. The seated resident extended her right hand and asked the other resident to stop, at which point the other resident grasped the top of her right hand, causing a skin tear on the dorsal right hand. During the same timeframe, the aggressor resident was also observed on camera grabbing and shaking other residents’ wheelchairs in the dining area. Seven staff members later stated they did not witness the actual altercation and only became aware when the injured resident called for help or was observed bleeding. The injured resident had a history of generalized muscle weakness, need for assistance with personal care and ambulation, major depressive disorder, and type 2 diabetes, with a BIMS score indicating moderate cognitive impairment. She reported to the surveyor that a man in the building had “stabbed” her hand by digging his fingers between her thumb and index finger, and she stated that she did not feel safe and was staying in her room because that was where she felt safe. During a subsequent joint visit with the social worker and surveyor, she again expressed anger that the man was still “roaming the facility,” stated she felt unsafe outside her room, and said she had a plan to fight back if he came near her. Wound assessments documented a painful right-hand skin tear with sanguinous/serosanguinous drainage that persisted over multiple assessments. The resident who caused the injury had diagnoses including dementia, psychotic disorder with delusions, mood disorders, generalized anxiety disorder, and type 2 diabetes. His behavior care plan, initiated months earlier, documented that he could be combative, wander into other residents’ rooms, and hit out at other residents. The care plan goal was that he would have no evidence of behavior problems, with an intervention for caregivers to provide opportunities for positive interaction when passing by. Although the care plan showed a revision date after the altercation, it did not add any specific interventions to address his combativeness or to protect other residents from harm, and the behavior care plan was not updated following the resident-to-resident altercation. This failure to revise and individualize the behavior care plan, in the context of known behavioral risks and an actual physical altercation resulting in injury, constituted the cited deficiency in protecting residents from abuse.
Significant Medication Errors Involving Flexeril and Fentanyl Patch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to both a scheduled muscle relaxant (Cyclobenzaprine/Flexeril) and a Fentanyl patch. During a medication pass observation, the nurse reported that the resident’s Flexeril was not available for the 1:00 PM dose and that it had also been unavailable for the 5:00 AM dose that same day. The nurse stated she had learned from the night shift that the last Flexeril dose was given the previous evening and that the pharmacy had reported it was too early to refill, with the next delivery not due until later in the month. The medication was not available in the emergency backup box, and the nurse did not notify the physician on call when the doses were missed. The resident had diagnoses including pain, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and depression, and had an opioid pain management care plan. The physician later confirmed that neither he nor his associates had been informed about the missed Flexeril doses and stated that missing a scheduled pain-relief medication without physician notification constituted a medication error. Pharmacy records showed that a 30‑day supply of Flexeril had been dispensed and should have lasted until a later date, indicating approximately nine days’ worth of doses (27 tablets) were unaccounted for. The DON acknowledged that the Flexeril was unavailable, that two doses were missed on the day of the survey, and that no provider had been notified when the medication first ran out. A second medication error was identified when a Fentanyl patch was observed on the resident’s chest, dated several weeks earlier, despite there being no current physician order for the patch. The resident requested its removal, stating it had been in place for weeks. Upon review, the DON confirmed that the Fentanyl patch order had been discontinued several weeks prior, yet the patch remained on the resident’s body and had not been removed at the time of discontinuation. The consultant pharmacist confirmed there was no active order for the Fentanyl patch and that it should have been discontinued, and also explained that Flexeril was not stocked in the backup box because the facility had not requested it and that early refills required facility authorization. Facility policies reviewed required that medications be administered as prescribed and that procedures be in place for when medications are delayed or unavailable, but these were not followed in this case, resulting in the identified medication errors.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents. Resident #1, who was admitted with multiple diagnoses including dementia and schizophrenia, was found in a room cluttered with large bags of clothes and towels, some of which were not identified as belonging to the resident. The bathroom in Resident #1's room was observed to be unclean, with orange-brown stains in the toilet bowl and yellow stains on the floor beneath the sink. Additionally, there was a lack of clean towels and washcloths available for resident use, as noted during a tour of the facility's laundry and linen storage areas. Resident #5, who had severe cognitive deficits and required assistance with all care, was found to have a bathroom with a large dark orange stain in the sink and similar stains in the toilet. The floor was also soiled with yellow stains, and an unlabeled bedpan was left on a commode chair. The facility was unable to provide a housekeeping policy for daily cleaning or a linen policy when requested. The administrator acknowledged staff turnover in the housekeeping and maintenance departments, which may have contributed to the deficiencies observed.
Failure to Maintain Bladder Scanner Leads to Resident Complications
Penalty
Summary
The facility failed to maintain essential equipment, specifically the bladder scanner, in good repair, which was necessary for assessing residents with urinary retention. This deficiency was identified during the review of a resident who had been diagnosed with urinary retention, elevated PSA, chronic kidney disease, and chronic respiratory failure. The resident was on a trial void order, which required the use of a bladder scanner to monitor urinary retention. However, the scanner was found to be inoperable, and staff were unaware of its condition until it was needed. On the day of the incident, the resident experienced severe abdominal pain, and staff were unable to measure urinary retention due to the broken bladder scanner. Despite attempts to reinsert a Foley catheter, the procedure was unsuccessful, and blood clots were observed, prompting the need to send the resident to the emergency room for catheter reinsertion. Interviews with nursing staff and the nurse practitioner revealed that the bladder scanner's malfunction was not reported or addressed in a timely manner, leading to complications in the resident's care. The Director of Nursing and the Administrator were both unaware of the bladder scanner's condition until after the incident. The Administrator admitted that no attempts were made to repair or replace the equipment, despite its critical role in resident care. The facility's policies on equipment maintenance and bladder scanner usage were reviewed, highlighting the expectation for timely repairs and the provision of backup devices, which were not followed in this case.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to implement and carry out interventions to prevent the development of pressure ulcers for a resident, resulting in the development of four facility-acquired pressure ulcers. The resident, who is severely cognitively impaired and receiving hospice services, was observed with multiple pressure ulcers, including those on both elbows and the left and right iliac crest, which were identified as facility-acquired. The care plan for the resident included interventions such as an air mattress, wedge for positioning, and offloading of heels, but these were not consistently implemented, as observed during the survey. The resident was frequently observed lying on their back without the necessary positioning aids, such as a wedge cushion, and with inconsistent use of elbow protectors. The LPN interviewed acknowledged the presence of new pressure ulcers and stated that interventions like turning the resident every two hours and using elbow guards were in place, but the pressure ulcers still developed. The LPN also mentioned the completion of an Unavoidable Skin Condition Form, which was not initially found in the electronic medical record. The facility's policy on skin management outlines the need for a comprehensive care plan addressing risk factors, preventative devices, and regular evaluation of pressure injuries, which was not fully adhered to in this case.
Deficiency in CNA Annual Competency Training
Penalty
Summary
The facility failed to maintain the required annual-based competencies and education of 12.0 hours for three Certified Nursing Assistants (CNAs) reviewed. CNA N, hired in 2013, had an in-service training record that did not specify the number of hours attended, lacked competency assessments, and had no validation of lessons by the instructor. Similarly, CNA P, hired in 2023, had education checklists without quantified in-service minutes or competency assessments. CNA O, recently hired, had no written record of in-service hours completed during orientation. The Human Resources Director acknowledged the absence of an electronic learning system to track training hours and records for each staff member. Although an electronic tracking record for CNA P was later submitted, it showed only 7.58 hours of training, falling short of the required 12.0 hours. No records were provided for CNAs N and O. The facility's policy mandates maintaining individual in-service logs and ensuring evaluations for each in-service, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medication carts and treatment carts, as well as the appropriate storage of medications. On multiple occasions, medication carts were observed unlocked and unattended, with no nurse in the vicinity. This included a treatment cart in the 300-hall entrance and dining area, and a medication cart in the 300 Hall, which was left unlocked with resident information exposed on the computer screen. Additionally, medications such as Fluticasone nasal spray and Artificial Tears were found without proper labeling, lacking resident identification and open dates. Glucose monitoring test strips were also found open and undated. Furthermore, the facility did not adhere to its policy of separating topical treatments from oral medications. Topical creams such as capsaicin, hydrocortisone, and estradiol were stored alongside oral medications and breathing treatments in the medication cart, contrary to facility policy. The staff acknowledged these lapses, with nurses indicating that the carts should be locked and medications properly labeled and stored. The facility's policies, dated November 2021, clearly state that medication carts should be locked when not attended and that oral and topical medications should be stored separately.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a respectful and dignified manner, as evidenced by multiple observations and interviews. Residents reported that call lights were not answered in a timely manner, with some waiting up to 45 minutes to an hour for assistance, particularly for toileting needs. This delay in response led to residents experiencing soiled briefs and feelings of frustration, anger, and embarrassment. Additionally, call lights were often found out of reach, preventing residents from being able to summon help when needed. Further issues were identified with staff behavior, as residents reported that staff members were frequently observed talking on personal cell phones while providing care. This behavior was noted to be disrespectful and intrusive, as residents could overhear personal conversations. The facility also failed to adequately address grievances raised by residents, with reports indicating that grievances were not consistently followed up on, leaving residents feeling unheard and disrespected. Specific cases highlighted in the report include Resident #20, who was found with a call light on the floor, out of reach, and Resident #41, who experienced extended wait times for assistance, resulting in discomfort and pain. Resident #41 also reported an incident where she fell over in bed and was left in that position without assistance. These deficiencies reflect a broader issue of inadequate staffing and resource allocation, as evidenced by the lack of sufficient housekeeping and laundry services, leading to unclean hallways and delayed laundry returns.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in both resident care areas and the kitchen, potentially affecting all 55 residents. In one instance, a door leading to a furnace and piping in a resident's room was found open and could not be closed by housekeeping staff, posing a safety risk. The maintenance director later confirmed that the door was left open after a pest control inspection and was unaware it had not been shut or locked. Additionally, the main dining room floor was observed to be sticky, and a resident's room had a strong smell of urine with stained carpet, indicating a lack of cleanliness. In the kitchen, several issues were identified, including stagnated water with a sewage smell under the three-compartment sink, a non-functional chemical treatment machine, and drain flies. Another drain emitted a strong sewage odor and was not in use, while a third drain had a water leak causing a puddle on the floor. The maintenance manager was unaware of the leak, and no maintenance logs or records were available for review. These deficiencies highlight significant lapses in maintaining a sanitary environment, which could lead to foodborne illnesses and dissatisfaction with living conditions.
Failure to Implement Timely Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for two residents, resulting in inadequate guidance for staff to provide effective care. Resident #307, who was admitted with multiple serious health conditions including cancer and respiratory issues, was observed having difficulty chewing and required a different textured diet. However, the care plan addressing his nutritional needs was not created until four days after admission, leaving staff without necessary instructions to address his immediate dietary needs. Similarly, Resident #308, who had complex medical conditions including diabetes and chronic kidney disease requiring dialysis, did not have a care plan addressing his dietary needs until six days post-admission. Although a dialysis care plan was in place, it lacked any mention of dietary requirements. This delay in care planning resulted in the absence of specific instructions for staff to manage his nutritional intake effectively, as evidenced by his partially eaten meal and non-verbal dissatisfaction with his breakfast.
Failure to Implement CPAP Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's use and maintenance of a CPAP machine. The resident, who was admitted with diagnoses including diabetes, weakness, and obstructive sleep apnea, was observed using a CPAP machine that was not properly maintained. The resident reported that the CPAP mask and tubing had never been changed since their admission, and there was no documentation in the medical record regarding the cleaning of the CPAP or the replacement of its components. Additionally, the care plan for the resident did not include any information about the use and maintenance of the CPAP machine. The resident, who had moderate cognitive impairment, indicated that they had long used a CPAP machine and were aware of the need for regular maintenance, such as changing the mask every 30 days. Despite the resident's awareness and requests for the mask to be changed, the facility did not address these needs. An interview with the MDS Program Director confirmed that a care plan for the CPAP should have been in place, but it was missed. The facility's policy requires that each resident have a current and individualized care plan developed within seven days of arrival, which was not adhered to in this case.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with limited range of motion, resulting in the potential for decline in independence and physical ability. The resident, who was cognitively intact, had impairments in both lower extremities and required varying levels of assistance with daily activities. Despite being discharged from physical and occupational therapy with a home exercise program, there was no documentation of a restorative therapy plan or program in the resident's medical record. Interviews with the resident revealed that she was unaware of any restorative therapy plan following her physical therapy. The Director of Nursing confirmed the absence of a restorative team and mentioned ongoing efforts to train CNAs to become restorative aides, although the training had not been completed. The Therapy Program Manager acknowledged that the resident was a good candidate for a restorative therapy program and that such a program would not hinder her access to future therapy services. The facility's policy on restorative nursing programs indicated that such programs should be initiated when a resident is discharged from formalized rehabilitation therapy. However, the policy was not followed, as evidenced by the lack of a restorative program for the resident. The Administrator noted that the restorative therapy program had been discussed in a quality assurance meeting, but it had not yet been implemented.
Improper Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for several residents, leading to potential health risks. Resident #23, who has moderate cognitive impairment and uses a CPAP machine for obstructive sleep apnea, reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The resident indicated that the CPAP machine was provided by the facility, and the Director of Nursing (DON) confirmed that there was no batch order for cleaning, which should have been documented. Resident #34, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with a nebulizer that had moisture and liquid remaining in the medication chamber, indicating improper cleaning and storage. The resident's family member was unsure about the frequency of nebulizer use, and the DON acknowledged that nebulizer equipment should be cleaned and dried before storage to prevent mold growth. The facility's policy requires nebulizer equipment to be washed and air-dried completely before storage, but this was not followed. Resident #9, who has severe cognitive impairment and uses oxygen therapy, was observed with oxygen tubing that was not labeled or dated. The resident was seen using a portable oxygen tank, and the oxygen concentrator tubing was found in a bag without a date. The DON and a registered nurse both indicated that the tubing should be labeled and dated according to facility policy, which was not adhered to. The facility's policy mandates that oxygen delivery devices be changed weekly and stored in a clean bag when not in use, but these procedures were not followed for Resident #9.
Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to ensure complete and accurate documentation and assessment for a resident requiring dialysis care. Resident #308, who has multiple diagnoses including chronic kidney disease and requires renal dialysis, was admitted with a right-sided permacath for dialysis. However, the facility's records, including physician orders and care plans, did not accurately reflect the resident's dialysis access site or provide appropriate monitoring instructions. The care plan incorrectly mentioned a graft or fistula instead of the permacath IV catheter, and there was no mention of the permacath in the care plan to prevent adverse events. Additionally, the Hemodialysis Communication Forms for the resident lacked information about the dialysis access site, which is crucial for monitoring potential adverse effects or infections. The facility's policy on dialysis care did not address the specific needs of residents with a permacath, focusing instead on fistulas. Interviews with the Director of Nursing and RN Unit Manager revealed that they were unaware of the omission and planned to investigate further. The hospital discharge instructions, which included keeping the permacath clean and dry, were not incorporated into the facility's plan of care.
Deficiency in Daily Clinical Staff Postings
Penalty
Summary
The facility failed to ensure that clinical staff postings were completed and available for review for multiple days from January 2024 to August 2024. This deficiency was identified through observation, interview, and record review. The Director of Nursing (DON) stated that the Clinical Staff posting document, known as the Staffing Report, was supposed to be completed daily by the Scheduler and posted on the wall by the nurses' desk. This document was intended to show the number of RNs, LPNs, and CNAs staffed each day, along with the total hours worked per shift and the resident census. However, upon review, it was found that the daily reports for July 2024 were missing, except for one day, and several documents from January and February 2024 were also missing or incomplete, lacking staff hours and census data. The Scheduler D explained that she started the forms with information from the nurses' schedule and then sent them to the nursing supervisor. On days she was not working, she would send the documents in advance to the receptionist for completion. However, the receptionist stated she did not handle these forms and was unaware of their contents. The Scheduler D acknowledged that some forms were incomplete and could not locate the missing staffing forms from July 2024. The facility's policy on the assignment of nursing care, which was reviewed and revised in August 2024, required nursing assignments to be based on the number of staff on the units, but this was not adhered to due to the incomplete and missing staffing reports.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of an antipsychotic medication for a resident, resulting in the potential for the administration of unnecessary medication. The resident, who was readmitted to the facility with multiple diagnoses including Alzheimer's dementia, depression, and anxiety, was prescribed Risperdal, an antipsychotic medication, without documented consent. A psychiatric consultation from a previous admission was found in the resident's record, but it did not specify any medications or provide clear consent for the current treatment. The facility's policy requires that residents or their responsible parties be informed of the risks and benefits of psychotropic medications and that informed consent be documented in the medical record. However, the documentation for this resident was incomplete and did not meet the facility's policy requirements. This oversight in obtaining and documenting informed consent for psychotropic medication use highlights a deficiency in the facility's medication management process.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #59, who had severe cognitive loss and required supervision with mobility, was found in her room with Resident #309, who had moderate cognitive impairment. Resident #309 was discovered by a CNA with his hand down Resident #59's pants. The CNA immediately intervened and reported the incident to the nurse and the administrator. The investigation revealed that Resident #309 had a history of wandering and had previously been involved in a consensual relationship with another resident. Despite this history, there were no care plans or physician orders in place to address Resident #309's wandering or sexually inappropriate behavior. The facility's intervention of implementing hourly checks was ineffective in preventing Resident #309 from entering female residents' rooms. The facility's documentation, including progress notes and social services assessments, failed to accurately reflect Resident #309's behavior. The discharge planning review did not mention Resident #309's sexually inappropriate behavior, and the facility's abuse reporting policy did not address resident-to-resident abuse. This lack of documentation and planning contributed to the failure to protect Resident #59 from abuse.
Incomplete Documentation and Investigation of Resident Fall
Penalty
Summary
The facility failed to retain documentation regarding an injury after a fall investigation for a resident, resulting in missed opportunities to prevent potential abuse or neglect. The incident involved a resident who was found on the floor by a CNA, attempting to leave the facility. The initial incident report was incomplete, with unchecked boxes and missing pertinent information, such as pain level and mental status. The resident was later diagnosed with an acute traumatic injury of the spine, which was not documented in the facility's investigation. The Director of Nursing (DON) acknowledged the incompleteness of the incident report and attributed it to an agency nurse who was responsible for filling it out. The DON, who was new to the position at the time, did not recall many details of the incident. The facility's investigation lacked interviews, staff involvement lists, and written statements, and there was no documentation to support the conclusion that neglect was not substantiated. The facility's policy required retention of internal investigation reports for four years and nursing incident reports for three years, but the documentation for this incident was not retained. The facility's Falls Management Guideline emphasized the importance of reviewing and updating the resident's plan of care following a fall, but this was not done in this case. The Administrator confirmed the investigation was incomplete and should have been retained, especially since it was reported to the State Agency.
Delayed Nutritional Assessments and Monitoring
Penalty
Summary
The facility failed to ensure timely interventions to promote nutrition for two residents, resulting in a lack of timely assessments and monitoring of their nutritional needs. Resident #307 was admitted with multiple serious diagnoses, including cancer and respiratory failure. Despite the family's concerns about the resident's difficulty chewing and the need for a different textured diet, the facility did not accurately document the resident's food intake or address the chewing problem until four days after admission. The initial dietary assessment and care plan were delayed, and the resident's nutritional needs were not promptly addressed. Resident #308, who was admitted with conditions such as diabetes and chronic kidney disease requiring dialysis, also experienced delays in nutritional assessment and care planning. The resident's dietary preferences were not assessed until five days after admission, and there was inconsistency in documenting meal intake. The resident was not eating well, and the facility did not consistently monitor his nutritional needs, despite the increased risk due to dialysis. The dietary profile and care plan were completed six days after admission, indicating a significant delay in addressing the resident's nutritional requirements. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, including participating in care planning. However, the delayed assessments and inconsistent documentation of meal intake for both residents indicate a failure to adhere to this policy. The lack of timely intervention and monitoring of nutritional needs for these residents highlights deficiencies in the facility's processes for ensuring adequate nutrition and care planning.
Failure to Follow Enteral Feeding Orders and Document Intake
Penalty
Summary
The facility failed to adhere to physician's orders and facility policy regarding enteral feeding for a resident with severe cognitive impairment and multiple medical conditions, including dysphagia and cerebral infarction. The resident was observed receiving enteral feeding at a rate of 50ml/hr, contrary to the physician's order of 60ml/hr for 16 hours. This discrepancy resulted in the resident not receiving the total ordered amount of 960ml of enteral feeding. Additionally, there was a lack of documentation regarding the total amount of enteral feeding infused, as the facility's Medication Administration Record (MAR) only indicated the start and stop times of the feeding. The Director of Nursing (DON) acknowledged that the feeding rate had been reduced due to the resident experiencing nausea, but there was no system in place for staff to document the total intake when the rate was adjusted. The facility's policy on enteral tube care and maintenance requires the pump to be cleared at the end of each shift after documenting the total amount infused, which was not followed. The DON assumed that the resident was receiving the total ordered amount based on staff signing off on the order, despite the lower infusion rate and lack of documentation.
Inadequate Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of lung cancer with metastasis to the liver and bone, pulmonary edema, respiratory failure, pneumonia, and glaucoma. Upon admission, the resident was not promptly assessed or provided with effective pain relief, resulting in the resident experiencing significant pain and discomfort. The resident's family reported that the pain medication provided was not effective, and there was a delay in processing new medication orders from the physician. The resident was initially given Tylenol, which did not adequately manage the pain, as indicated by the resident's pain rating of 10 on a 0-10 scale. Further complications arose when the resident was administered Morphine and Lorazepam simultaneously, which the family and resident found too sedating. The facility's care plan for the resident was not initiated until two days after admission, despite the resident's high risk for pain due to their medical condition. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and allowing them to participate in care planning, which was not adhered to in this case.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure that medications were available and administered timely as ordered for two residents, resulting in medication errors. During a medication administration observation, it was noted that a Lidocaine 4% Patch for one resident and Lantus insulin for another resident were unavailable. The Lidocaine Patch was not in stock, and no backup supply was available, leading to a delay in administration. The insulin was unavailable because the resident had just been admitted, and the medication had not yet been delivered by the pharmacy. The Director of Nursing confirmed that the Lidocaine Patch was reordered three days prior but was not delivered as expected. The insulin was not available in the backup medication supply, and the pharmacy had not restocked it. The facility's policy requires medications to be administered as prescribed, but the unavailability of these medications led to a medication error rate of 6.25% during the observation period. The failure to provide these medications as ordered resulted in potential adverse reactions for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate during a medication administration observation. This deficiency was identified when two medications were omitted for two residents. The first resident, who was cognitively intact with a BIMS score of 15/15, did not receive their prescribed Lidocaine 4% patch due to its unavailability in the facility. The nurse attempted to locate the patch in the stock/storage medication rooms but found none available and informed the Director of Nursing (DON) about the situation. The patch was reordered three days prior but was not delivered as expected. The second resident, admitted with multiple diagnoses including diabetes mellitus, did not receive their scheduled Lantus insulin injection because it was unavailable. The nurse discovered the absence of the insulin while preparing the resident's medication and was unable to find it in the backup kiosk. The DON explained that the insulin was unavailable due to the resident's recent admission and the pharmacy's delay in restocking. Both incidents contributed to the facility's medication administration error rate exceeding the acceptable threshold.
Medication Errors and Pain Management Deficiency
Penalty
Summary
The facility failed to prevent significant medication errors for a resident, resulting in the potential for serious adverse effects. The resident, who was recently admitted with multiple diagnoses including diabetes mellitus and vertebrogenic low back pain, did not receive their prescribed Lantus insulin injection due to its unavailability. Nurse K, responsible for administering the medication, was unable to locate the insulin in the backup medication supply and did not administer it as scheduled. Additionally, there was an error in the medication order for Insulin Glargine, which incorrectly stated to administer it by mouth, indicating a route error. Furthermore, during the morning medication pass, Nurse K did not assess the resident's pain level before administering a single tablet of Tylenol, despite the resident expressing a pain level of 6 out of 10 and a preference for stronger pain relief. The resident had an active order for Norco for moderate to severe pain, which was not considered. The Director of Nursing acknowledged the unavailability of the Lantus insulin due to the recent admission, and the facility's policy was reviewed, highlighting the need for proper medication administration and availability.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in the absence of progress notes in the medical record. The resident, who is severely cognitively impaired and receiving hospice services, was admitted to the facility with diagnoses including dysphagia, cerebral infarction, traumatic brain injury, and pressure ulcers. A record review revealed that the most recent hospice note in the electronic medical record was from over two months prior, despite the resident being admitted to hospice care several months earlier. Interviews with facility staff, including the medical records personnel and the Director of Nursing, confirmed the lack of recent hospice documentation. The medical records staff acknowledged that the hospice company involved was new to the facility and had not been sending notes as frequently as other companies, which typically provide updates within a week. The Director of Nursing stated that the goal is to receive progress notes weekly, aligning with the facility's policy that emphasizes regular communication and documentation from hospice agencies.
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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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