Caretel Inns Of Tri-cities
Inspection history, citations, penalties and survey trends for this long-term care facility in Bay City, Michigan.
- Location
- 6700 Westside Saginaw Road, Bay City, Michigan 48706
- CMS Provider Number
- 235635
- Inspections on file
- 31
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Caretel Inns Of Tri-cities during CMS and state inspections, most recent first.
A resident with severe medical conditions was readmitted without a physician order for enteral feeding, resulting in nearly 19 hours without tube feeding or nutrition. Staff did not document timely notification to the physician about the missed feeding, and essential hospice and hospital discharge documents were missing from the record. The resident's condition worsened, leading to rehospitalization.
Nursing staff failed to clarify admission orders, reconcile medications, and provide timely medication administration for two residents after readmission, resulting in missed enteral feeding, administration of oral medications despite NPO status, lack of physician notification, and delayed administration of critical gastrointestinal medication due to unavailability in backup supply. These failures led to delayed care and rehospitalization.
Two residents experienced injuries related to improper transfer and lack of timely assessment: one developed bruising and sling indentations due to use of an incorrect Hoyer sling size despite care plan instructions, while another, who was non-ambulatory with severe contractures, sustained a leg fracture of unknown origin that was not promptly or accurately assessed or reported by staff, with no clear documentation or explanation for the injury.
Two residents experienced falls with injuries due to the facility's failure to implement and operationalize fall prevention policies, including lack of staff adherence to care plans, inadequate supervision, and absence of meaningful interventions. One resident suffered a hip fracture after being assisted by only one CNA instead of two, while another had multiple falls, resulting in a rib fracture and UTI, with insufficient preventive measures in place.
A resident with multiple chronic conditions, including contractures and immobility, sustained acute fractures of the right tibia and fibula. Despite the new injury and the use of an orthopedic boot, the care plan was not updated to include interventions for the fractures, pain management, or positioning. Staff and family were unable to determine how the injury occurred, and documentation review showed no revisions to address the resident's changed care needs.
A resident with immobility and recent fractures developed two Stage II pressure ulcers on the upper left shoulder due to inadequate repositioning, lack of updated care plan interventions, and insufficient documentation of wound assessment and physician notification. Nursing staff did not consistently follow the facility's pressure injury prevention policy, and wound measurements and records were only completed after surveyor observation.
A resident with advanced dementia and palliative care needs sustained a fractured right leg of unknown origin, with evidence suggesting inadequate supervision and inconsistent transfer practices between facility and hospice staff. The injury was discovered after bruising and swelling were noted, and no clear cause was identified, highlighting a failure to prevent accident hazards and ensure proper care coordination.
Two residents who requested alternative menu items were served unappetizing, poorly presented, and cold food, with missing condiments and small portions. Both expressed dissatisfaction and one refused to eat. Ongoing complaints from resident council meetings and staff interviews confirmed persistent issues with food quality, temperature, and service, in violation of facility policies requiring palatable and dignified meal service.
A resident admitted with pneumonia and sepsis did not receive scheduled evening medications on the day of admission due to delays in medication entry and administration, despite some medications being available in the facility's backup supply. The admission process spanned two shifts, and the concern about missed medications was not documented or addressed by facility leadership.
A facility failed to assess and treat a resident's UTI and foot wounds, leading to hospitalization. The resident, with a history of multiple health issues, showed signs of a UTI and had wounds on the feet that were not documented or treated. Upon hospital transfer, the resident was diagnosed with a complicated UTI, acute kidney injury, and osteomyelitis, eventually leading to hospice care and death. Interviews with staff confirmed the lack of documentation and treatment, and issues with laboratory services were noted.
The facility failed to follow catheter care policies and obtain urinalysis testing for three residents. A resident with a history of UTI had no urinalysis results despite a physician's order. Another resident expressed concerns about infrequent catheter emptying, confirmed by documentation and observation. A third resident's catheter was not emptied as per policy. The facility acknowledged issues with documentation and laboratory services.
A resident with severe cognitive impairment and limited mobility developed a facility-acquired Stage III pressure ulcer due to delayed wound assessment, lack of timely treatment, and inadequate documentation. The care plan was not promptly updated with new interventions, and pressure-relieving equipment was found to be in poor condition. Observations during wound care revealed improper dressing technique and the presence of fecal matter in the wound area, highlighting failures in both prevention and treatment of pressure ulcers.
A resident with a history of circulatory surgery and cognitive impairment developed an unstageable coccyx pressure ulcer due to the facility's failure to implement timely interventions. Despite being at risk, necessary measures like an air mattress were not used, leading to infection and hospitalization. The facility's records did not show any refusal by the resident to reposition, which was noted as a factor inhibiting wound healing.
A facility failed to ensure proper PPE use and hand hygiene for a resident requiring enhanced barrier precautions. Staff entered the resident's room without gowns, stored gloves in pockets, and did not perform hand hygiene before donning gloves. The resident had bloody drainage and open sores, and the necessary PPE was not available, leading to potential cross-contamination.
The facility failed to maintain cleanliness and organization of medication carts in three halls, with observations revealing crushed pills, papers, and dried liquids in drawers, and loose pills in another cart. Interviews indicated confusion over cleaning responsibilities, with the DON stating night shift nurses were responsible. Facility policies on medication storage and night shift duties were not adhered to, as there was no documentation of cart maintenance.
The facility failed to maintain cleanliness in its food service area, affecting 50 residents. Equipment such as the coffee machine, blender, and meat slicer were found with encrusted food residue, while the air conditioning unit above the steam table was heavily soiled. The facility's cleaning policies were not adhered to, increasing the risk of cross-contamination.
The facility failed to maintain cleanliness and proper labeling in the residents' refrigerator, with various food items found without labels or dates. The Infection Control Nurse admitted to not inspecting the refrigerator and was unaware of any cleaning policy. Additionally, the facility did not analyze monthly infection control data, with summaries lacking documentation of data analysis. The Infection Control Nurse had only received minimal training, indicating a lack of proper training and oversight.
The facility failed to maintain a clean and safe environment, affecting 50 residents. Observations showed damaged and soiled equipment in common areas, scuffed walls, and paint chips in a resident's room. A family member reported doing laundry due to inadequate facility services. A review revealed 51 rooms needing repairs, indicating maintenance backlogs.
A facility failed to implement a baseline care plan for a resident's oxygen administration, leading to unmet care needs. The resident, admitted with chronic respiratory issues, had unlabeled oxygen tubing and no care plan in the EHR despite a physician's order for oxygen use. An LPN acknowledged the oversight, and the DON was informed of the missing care plan.
A facility failed to label oxygen tubing with the date it was changed for a resident with chronic respiratory conditions, leading to a deficiency in infection control. Observations showed unlabeled tubing despite a physician's order for weekly changes. An LPN confirmed the need for labeling and a care plan, and the DON was informed of the oversight.
A resident admitted with an unstageable pressure injury experienced inadequate care and documentation. The facility failed to consistently stage and measure the wound accurately, with discrepancies noted in the assessments. The facility's policy required weekly documentation, which was not followed, leading to a deficiency. The DON confirmed the inaccuracies and noted a past noncompliance issue related to pressure injuries.
Failure to Reconcile Enteral Feeding Orders Resulting in Missed Nutrition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic hypoxic respiratory failure, severe protein-calorie malnutrition, septic shock, diabetes type 2, and a gastrostomy, was readmitted to the facility. Upon readmission, there was no physician order for enteral feeding/nutrition, and an NPO (nothing by mouth) order was in place. The resident did not receive tube feeding or nutrition for approximately 19 hours following readmission, as documented in the electronic medical record (EMR) and confirmed by staff interviews and record reviews. Progress notes indicated that staff were aware the resident had not received their prescribed Glucerna tube feeding since returning from the hospital, and the feeding was not initiated until the following morning after staff made calls to confirm orders. There was no documentation clarifying who was contacted for the order, nor was there evidence that the physician was notified of the missed tube feeding. Additionally, the resident's condition deteriorated, with lethargy, decreased oxygen saturation, and a high glucose level, leading to rehospitalization. Further review revealed that hospice documentation and hospital discharge medication lists were missing from the EMR at the time of readmission, and the hospice nurse may have inadvertently taken these documents. The facility's admission policy requires written physician orders for immediate care, including dietary instructions, but these were not present. The lack of clear orders and documentation resulted in a failure to provide essential tube feeding/nutrition to the resident for an extended period.
Failure to Clarify Admission Orders and Timely Medication Administration
Penalty
Summary
Nursing staff failed to clarify admission orders, reconcile medications, provide timely medication administration, and coordinate with hospice and the physician for two residents following their readmission. For one resident with multiple complex diagnoses, including chronic hypoxic respiratory failure, severe malnutrition, and diabetes, there was no documentation of hospice admission paperwork or clarification of orders upon readmission. The resident was ordered NPO, but oral medications were still administered and documented, and there was no order or administration of enteral feeding for nearly 19 hours. The medical record lacked evidence of physician notification regarding the missed tube feeding, and the Director of Nursing (DON) was unaware of the lapse until it was pointed out during the survey. Additionally, the hospice nurse reportedly took the hospital discharge paperwork, and there was no documentation of communication with the physician or hospice to clarify orders or obtain missing information. For the same resident, progress notes indicated that the resident did not receive prescribed tube feeding upon return from the hospital, and the feed was only started the following morning after staff made calls to confirm orders. There was no documentation specifying who was contacted, what orders were clarified, or if the physician was notified about the missed feeding. The resident later became lethargic, experienced a significant drop in oxygen saturation, and had a critically high blood glucose level, leading to rehospitalization. The facility's admission policy required written physician orders for immediate care, including dietary instructions and medications, but these were not present or clarified at the time of admission. A second resident, readmitted with gastrointestinal diagnoses including esophageal ulcer and bleeding, did not receive scheduled gastrointestinal medication (Nexium) as ordered via PEG tube. The medication was not available in the facility's backup supply, resulting in missed doses until the evening after admission. The DON confirmed the importance of the medication given the resident's condition but stated that the medication was not administered until it was delivered the next day. The facility's backup medication list did not include Nexium, contributing to the delay in administration.
Failure to Prevent Injury and Properly Assess Changes in Condition During Resident Transfers
Penalty
Summary
A deficiency occurred when staff failed to prevent bruising and sling indentations during a mechanical transfer for a resident who was immobile, totally dependent on staff for all ADLs, and receiving hospice care. The resident had multiple diagnoses, including malnutrition, dementia, and a history of fractures. Despite a care plan specifying the use of a small sling for transfers, staff used an incorrect sling size, resulting in red indentation marks on both thighs and a new bruise above the right knee. The resident was observed to be in pain during the transfer, and the sling indentations matched the pattern of the sling used. Documentation confirmed that a small sling was available but not used as directed in the care plan. Another deficiency was identified when a resident with severe cognitive impairment, non-ambulatory status, and bilateral lower extremity contractures sustained a fracture of the right tibia and fibula of unknown origin. The resident was found with right ankle swelling, bruising, and pain, but staff were unable to determine or report how the injury occurred. The resident was unable to move or turn herself, and family members reported that she was bedridden and required a Hoyer lift for transfers. The incident was not promptly or accurately reported by the LPN on duty, who attributed the injury to pressure from the mattress and failed to document a physical assessment or notify appropriate personnel in a timely manner. Interviews and record reviews revealed that the facility lacked a clear nursing assessment policy for documenting changes in resident condition. The LPN did not obtain an order for a boot applied to the resident's foot and did not report the full extent of the injury to the next nurse. The injury was only escalated after a CNA showed a photo of the bruising to the RN, DON, and NHA, leading to further assessment and hospital transfer. The facility was unable to provide an explanation for the injury, and there was no documentation of skin monitoring or assessment at the time the injury was first noted.
Failure to Implement Fall Prevention Policies and Ensure Adequate Supervision
Penalty
Summary
The facility failed to implement and operationalize fall prevention policies and procedures for two residents, resulting in a lack of planned and meaningful interventions to prevent falls. One resident, who was cognitively intact and required total assistance for bed mobility and transfers, experienced a fall while receiving a bed bath from a single CNA, despite the care plan specifying the need for two staff members. The CNA did not review the resident's care plan prior to providing care and relied on previous training from another CNA. The resident rolled out of bed, which was positioned at waist height without a fall mat in place, and suffered a broken hip requiring emergency surgery. The incident was not immediately reported to the DON as involving a care plan violation, and the DON was unaware of the fracture until the resident returned from the hospital. Another resident, admitted with multiple medical diagnoses including dementia and a history of falls, experienced five falls within a short period. During one incident, the resident was found on the floor next to the bed and subsequently returned to bed without staff assistance. The resident stated he had jumped on the floor to get a drink. After being sent to the hospital, the resident was found to have a rib fracture and a urinary tract infection. The only intervention documented after the incident was to keep drinks within reach, but there was no evidence of a comprehensive fall prevention strategy or meaningful interventions to address the repeated falls. In both cases, the facility did not ensure that staff followed care plans or implemented adequate supervision and interventions to prevent accidents. Staff failed to review care plans before providing care, and there was a lack of assessment for assistive devices or environmental modifications. These failures resulted in residents experiencing falls with injuries, unnecessary pain, and a decline in overall health status.
Failure to Update Care Plan After Resident Sustained Acute Fractures
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for a resident following a significant change in condition. The resident, an elderly female with multiple complex medical diagnoses including muscle weakness, dysphagia, malnutrition, diabetes, mood disorder, Alzheimer's disease, and contractures of the lower extremities, sustained acute fractures of the right tibia and fibula. Despite the presence of an orthopedic boot and the resident being bedridden and non-weight bearing, there were no updates or new interventions added to her care plan to address the new fractures, the use of the orthopedic boot, or specific positioning and pain management needs related to the injury. Observation and interviews revealed that the resident and her family were unaware of how the injury occurred, and facility staff could not provide information regarding the onset of the injury or swelling. The hospital record confirmed the acute fractures and noted the resident's chronic contractures and immobility. Review of the care plan documentation showed no revisions or additions to address the resident's new care needs following the injury, and the chronic pain care plan did not include interventions for the acute fracture, positioning, or follow-up care.
Failure to Prevent and Document Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of two Stage II pressure ulcers on the upper left shoulder of a resident who was at high risk due to immobility and recent right leg fractures. Observations showed the resident was frequently positioned in a reclining Broda chair, leaning to one side for extended periods without repositioning, and with contractures limiting mobility. The care plan for skin integrity had not been updated with new interventions following the development of the pressure ulcers, and preventive measures such as regular repositioning and pressure relief were not adequately implemented. Record reviews revealed that wound care for the left shoulder began after the ulcers were discovered, but there was a lack of documentation regarding wound measurements, photographs, and timely physician progress notes. The wounds were first noted as blisters, and there was no evidence of comprehensive assessment or communication with the physician about the new pressure injuries or the resident's recent fractures. The facility's own policy required regular assessment, use of pressure redistribution devices, and individualized repositioning, but these were not consistently followed. Interviews with nursing staff and the DON confirmed that wound measurements and documentation were only completed after the surveyor's observation, and there was no prior photographic or measurement record of the wounds. The lack of timely assessment, documentation, and implementation of preventive interventions contributed to the development and progression of the pressure ulcers, as well as the resident's pain and discomfort.
Failure to Prevent Injury of Unknown Origin Resulting in Fractured Leg
Penalty
Summary
A deficiency occurred when a resident with significant medical vulnerabilities, including dementia, Alzheimer's, protein malnutrition, and palliative care needs, sustained a fractured tibia and fibula of the right leg while residing in the facility. The resident was nonverbal, frail, and dependent on staff for all care, including transfers with a mechanical lift requiring two staff members per facility protocol. However, hospice staff, who also provided care, reportedly used only one staff member for transfers. The resident was often positioned in a Broda chair, with observations noting her leaning to one side and her right heel positioned in the leg extension crack of the chair. Documentation from certified nursing assistants indicated no concerns with the resident's positioning or skin condition in the days leading up to the discovery of the injury. On the day the injury was identified, a hospice staff member noticed bruising on the resident's right ankle, which had not been present previously. Subsequent assessment revealed swelling and yellow/greenish bruising, and an X-ray confirmed fractures of the tibia and fibula. The cause of the injury could not be determined, but it was suggested by facility management and the resident's family that improper securing of the resident's legs during movement in the Broda chair or accidental bumping of the foot/ankle during transfers or transport may have contributed. Interviews with facility and hospice staff highlighted inconsistencies in care coordination and communication. Hospice aides did not consistently communicate with facility staff regarding the care provided, and there were differences in transfer practices between hospice and facility staff. The facility's investigation did not identify a specific cause for the injury, and the injury was classified as of unknown origin. The facility's abuse prevention policy prohibits neglect, but the lack of adequate supervision and coordination between facility and hospice staff led to the resident sustaining a significant injury.
Failure to Provide Palatable and Properly Presented Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, visually appealing, and at a preferred temperature, as observed during a noon meal. Two residents, both alert and dependent on staff for activities of daily living, requested hamburgers from the Always Available Menu instead of the main meal option. The hamburgers provided had smashed buns, very small meat patties, and were missing requested condiments such as onions and gravy. One resident was unable to add ketchup due to the condition of the food, and both residents expressed dissatisfaction, with one stating the food was cold and not tolerable, ultimately refusing to eat the meal. Further review of confidential Resident Council meeting notes over several months revealed ongoing complaints regarding the quality, temperature, and portion size of food, as well as not receiving ordered items. An interview with the Director of Activities confirmed awareness of continuous food complaints, describing the food as unappetizing and likening it to gas station food. Facility policies reviewed indicated requirements for food to be attractively presented, palatable, and for residents to be treated with dignity and respect, which were not met in these instances.
Failure to Timely Administer Admission Medications and Complete Admission Procedures
Penalty
Summary
The facility failed to timely and accurately complete the admission process and administer medications as ordered for a newly admitted resident. Upon review, it was found that the resident, who was admitted with diagnoses including pneumonia, sepsis, and a need for assistance with personal care, did not receive her scheduled evening medications on the day of admission. The resident's hospital discharge medication list included several medications due that evening, but the Medication Administration Record (MAR) showed that these medications were not scheduled to begin until the following day. Although one of the required medications, Eliquis, was available in the facility's backup supply, it was not administered. The resident arrived at the facility in the evening, after the cutoff for the nightly medication delivery, and the medications were not entered into the system until after midnight, spanning two nursing shifts. The process required one nurse to input all medications and a second nurse to review for accuracy and notify the physician, but this was not completed in a timely manner. Additionally, the facility administrator was unaware of a concern form submitted by the resident regarding the missed medications, and no documentation of this concern was found in the facility's records. The administrator explained that some records may have been lost when the previous DON left the facility.
Failure to Assess and Treat UTI and Foot Wounds
Penalty
Summary
The facility failed to properly assess, identify, and treat wounds on the feet and a urinary tract infection (UTI) for Resident #2, who was one of three residents reviewed for a change in condition. Upon re-admission, Resident #2 had multiple diagnoses, including difficulty walking, diabetes, and a history of UTI. Despite a progress note indicating blood-tinged urine and an order for urinalysis and culture, there were no results documented in the medical record. The resident's condition worsened, with dark orange urine and loose stools, leading to a physician's order for IV hydration and antibiotics. However, the family insisted on hospital transfer due to the resident's declining health. At the hospital, Resident #2 was diagnosed with a complicated UTI, acute kidney injury, and osteomyelitis of the right great toe. The hospital records revealed a foul-smelling discharge from the toe, which was not documented or treated at the facility. The resident's condition included dehydration and renal failure, and the family opted for hospice care after a discussion about potential amputation of the toe. The resident eventually passed away, with the death certificate citing acute osteomyelitis as the main cause of death. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, confirmed the lack of documentation and treatment for the resident's foot wounds and UTI. The facility's policy on preventing catheter-associated UTIs was not effectively implemented, as evidenced by the resident's condition upon hospital transfer. The facility also reported issues with their laboratory services, which may have contributed to the lack of timely diagnosis and treatment.
Plan Of Correction
1. Resident #2 no longer resides in the facility. 2. Like residents are identified as any resident with a change in condition. A sweep was conducted on 3/24/2025 to ensure all residents with catheters and any wound had care plan reviews. Like resident medical records were reviewed between 3/22/25 to 3/25/2024 to ensure appropriate interventions were in place for the prevention of skin breakdown and changes in condition were identified timely and reported to the MD appropriately and timely. All future residents admitted with potential risk factors will be identified upon admission and appropriate interventions implemented in the plan of care timely. 3. The Policy on reporting changes in condition has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate interventions implemented in their plan of care timely. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission with any change in condition between 3/13/25 and 3/21/2025. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.
Deficient Catheter Care and Urinalysis Testing
Penalty
Summary
The facility failed to adhere to its policies and procedures for catheter care and urinalysis testing for three residents. Resident #2 was readmitted with multiple diagnoses, including urinary retention and a history of urinary tract infection (UTI). Despite a physician's order for urinalysis and culture due to blood-tinged and cloudy urine, there were no urinalysis results in the medical record. The facility did not implement a task for documenting catheter care, and the Administrator confirmed that catheter care documentation was not performed. Resident #4, who had a Foley catheter and was dependent on assistance for mobility and toileting, expressed concerns about staff not emptying her catheter bag frequently enough. Documentation showed the catheter was emptied only once a day on several occasions, and not at all on one day, despite the facility's policy to empty the drainage bag every shift. An observation confirmed the resident's catheter bag was partially filled with urine and sediment. Resident #5, also with a Foley catheter, had documentation indicating the catheter was emptied only once a day on certain days and not at all on others. The facility's policy required emptying the catheter bag every shift, but this was not consistently documented or performed. The Administrator acknowledged issues with laboratory services and a lack of follow-up on urinalysis testing, contributing to the deficiency in care for these residents.
Plan Of Correction
1. Resident #2 no longer resides in the facility. Resident #4 is a long-term resident of the facility; the care plan was reviewed and was deemed appropriate. 2. Like residents were identified as those with Foley catheters and are at risk for developing urinary tract infections. Like residents' medical records were reviewed between 3/22/25 through 3/25/25 to ensure their plan of care includes interventions for the prevention of a urinary tract infection. 3. The policy regarding indwelling catheter care and maintenance was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate processes for initiating timely interventions upon admission and with any change of condition between 3/13/25 and 3/21/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for catheter maintenance are initiated timely upon admission. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.
Failure to Prevent and Timely Treat Facility-Acquired Stage III Pressure Ulcer
Penalty
Summary
A facility failed to operationalize its policies and procedures for skin and wound assessments and treatments, resulting in the development and worsening of a facility-acquired Stage III pressure ulcer for a resident. The resident, who had significant cognitive impairment, limited mobility, incontinence, and other comorbidities such as diabetes and Alzheimer's disease, was dependent on staff for most activities of daily living. Despite these risk factors, documentation showed that the resident did not have a pressure ulcer at the time of a recent assessment, but a new Stage III ulcer was identified later without timely assessment or intervention. There was a lack of timely wound assessment and treatment following the initial identification of the pressure ulcer. The wound was first identified on one date, but the first documented assessment by the wound care nurse occurred two days later. There was no documentation of wound care or dressing changes until several days after the wound was identified. Additionally, the physician and the resident's representative were not notified until several days after the wound was discovered. The care plan was not promptly updated with new interventions specific to the newly developed wound, and existing interventions lacked measurable details, such as specific repositioning intervals or air mattress settings. Observations revealed that the resident's pressure-relieving equipment, such as the wheelchair cushion, was in poor condition and had not been replaced in a timely manner. During a dressing change, improper technique was observed, including adhesive from the dressing being placed over the open wound bed and the presence of fecal matter in the wound area. Staff interviews confirmed gaps in documentation, assessment, and communication regarding the wound, as well as delays in updating care plans and implementing appropriate interventions.
Plan Of Correction
1. Resident #4 resides in the facility. It was identified that the resident's wound was in fact a Kennedy Ulcer, and the resident has been placed on hospice for additional support. 2. Like residents are identified as those with a Braden scale of 16 or less. A sweep was completed on 3/17/25 of all current residents to assess their current Braden scale. Like resident's medical records were reviewed between 3/17 through 3/20/25 to ensure their plan of care includes appropriate interventions for prevention of skin breakdown. All future residents admitted with a Braden score of 16 or lower will have appropriate interventions implemented in their plan of care timely. 3. The Policy on Skin Management has been reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate process for initiating timely interventions upon admission and with any change of condition between 3/13 and 3/20/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for skin prevention are initiated timely upon admission or any change of condition. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of Compliance 3/27/2025
Failure to Prevent Pressure Ulcer Leads to Infection and Hospitalization
Penalty
Summary
The facility failed to implement timely and appropriate interventions to prevent a pressure ulcer for a resident, resulting in an unstageable coccyx pressure injury, infection, and subsequent hospitalization. The resident was admitted with a history of circulatory system surgery, moderate cognitive impairment, and required assistance with personal care. Despite being identified as at risk for pressure ulcers upon admission, the facility did not implement all necessary preventative measures, such as an air mattress, which could have mitigated the risk of pressure ulcer development. The resident's condition deteriorated rapidly, with the pressure ulcer being identified as facility-acquired shortly after admission. The wound assessment revealed significant tissue damage and infection, with heavy growth of Proteus Penneri and Escherichia Coli. The resident exhibited symptoms of infection, including clammy skin, chills, and confusion, leading to hospitalization. The facility's records did not indicate any refusal by the resident to reposition, which was noted as a factor inhibiting wound healing. The facility's Skin Management Program required appropriate preventative measures for residents at risk, as indicated by a Braden Scale score of 18 or less. However, the interventions documented in the care plan were not fully implemented, contributing to the development and worsening of the pressure ulcer. The administrator acknowledged the oversight in not utilizing an air mattress upon admission, despite the resident's history of weight loss and recent heart surgery, which increased their vulnerability to skin integrity issues.
Inadequate PPE Use and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene during care for a resident requiring enhanced barrier precautions. Observations revealed that two CNAs and a nurse entered the resident's room without wearing gowns, and gloves were improperly stored in uniform pockets. The CNAs and nurse did not perform hand hygiene before donning gloves, and the CNAs handled the resident, who had bloody drainage and open sores, without wearing gowns, leading to potential cross-contamination. The resident's electronic medical record indicated a physician order for enhanced barrier precautions due to a knee incision. Despite this, the necessary PPE was not available in or outside the resident's room, and the staff did not adhere to infection control protocols. The administrator acknowledged the absence of PPE carts and the need for more carts due to issues with confused residents moving them. The report highlights the lack of adherence to infection prevention protocols, resulting in potential cross-contamination and inadequate infection control measures.
Medication Cart Cleanliness and Organization Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and organization of medication carts across three different halls, as observed during a survey. Specifically, the medication cart on the 300 Hall was found to have crushed pills, papers, and dried liquids in multiple drawers. Additionally, loose pills were discovered in the cart for Hall 100, visible between the metal lock box and the cart. Interviews with nursing staff revealed a lack of clarity regarding responsibility for cleaning the carts, with one nurse indicating it was the second shift's responsibility, while another, an agency nurse, was unaware of who was responsible. The Director of Nursing stated that night shift nurses were tasked with cleaning the carts. The facility's policies on medication storage and night shift duties were reviewed, revealing that the medication storage conditions were supposed to be monitored regularly, and the night shift was responsible for cleaning and stocking the medication carts. However, there was no documentation or observation of how the medication carts were maintained, indicating a lapse in adherence to these policies. This lack of proper maintenance and organization of medication carts could lead to issues such as medication not being taken, lost or uncounted medications, and potential contamination.
Failure to Maintain Cleanliness in Food Service Area
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in its food service area, affecting 50 residents. During an inspection, several pieces of equipment were found with accumulated and encrusted food residue, including a coffee machine, blender, microwave oven, meat slicer, and stand mixer. The Vulcan ovens and deep fat fryer were also observed with significant soil and grease deposits. Additionally, the air conditioning unit in the sub-kitchen was heavily soiled with dust and dirt, located directly above the steam table, which could contribute to cross-contamination and bacterial harborage. The facility's policies and procedures for cleaning and sanitizing equipment were reviewed, revealing a lack of adherence to the established cleaning schedules and procedures. The cleaning schedule was supposed to include both routine and deep cleaning tasks, but the observed conditions indicated these were not being followed. The meat slicer, in particular, had a detailed cleaning procedure that was not implemented, as evidenced by the soiled condition of the equipment. This lack of effective cleaning and maintenance increased the likelihood of cross-contamination and compromised air quality in the food service area.
Inadequate Infection Control and Refrigerator Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the residents' refrigerator, as observed during a survey. Various food items were found without labels or dates, including yogurt, salad dressing, spaghetti with meatballs, egg sandwiches, hard salami, cheese ziti, fruits, shrimp, fish, chicken, salad, bologna, miracle whip, and ice cream. The Infection Control Nurse, RN C, acknowledged that all items should be labeled with the guest's name, date, and room number, and discarded after three days. However, RN C admitted to never inspecting the refrigerator and was unaware of any facility policy regarding its cleaning. The Director of Nursing also confirmed the need for the refrigerator to be cleaned. Additionally, the facility failed to analyze monthly infection control data, which was evident from the review of the facility's Infection Control Program and monthly summaries for April, May, and June 2024. The summaries only included the total number of infections and residents on antibiotics, with no documentation of data analysis. Nurse C stated that she had only received two days of training and had not been trained on data analysis, indicating a lack of proper training and oversight in infection control practices.
Deficiencies in Facility Cleanliness and Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining a clean and safe environment, affecting 50 residents. Observations revealed that the microwave oven in the Family Dining Room was etched and scored, and the hand sink basin was chipped, exposing the cast iron sub-surface. In the Occupational Therapy/Physical Therapy area, the refrigerator and freezer were heavily soiled with food residue, and the microwave oven was similarly damaged. The Staff Break Room contained worn-out furniture with protruding inner padding and soiled appliances. The facility's housekeeping and maintenance policies were reviewed, but they lacked specific dates, indicating a possible lapse in adherence to cleaning and maintenance protocols. Further observations in a resident's room revealed heavily scuffed walls and a large amount of paint chips on the bathroom floor, which had been mopped over without being removed. The Director of Housekeeping/Maintenance acknowledged the issue but attributed it to staffing challenges. Additionally, a room inspection found soiled clothing in an open bag emitting a strong urine odor, and the carpet was stained. A family member expressed concerns about the cleanliness and stated they had been doing the resident's laundry due to inadequate facility services. A review of the facility's repair list showed 51 rooms requiring attention, highlighting significant maintenance backlogs.
Failure to Implement Baseline Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement a baseline care plan for a resident's oxygen administration, resulting in unmet care needs. The resident, who is of advanced age, was admitted with chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, and emphysema. Observations on two consecutive days revealed that the oxygen tubing used by the resident was not labeled with the date of the last change. A physician's order for oxygen administration via nasal cannula at a flow rate of 2 liters per minute was present, but there was no corresponding care plan in the electronic health record for oxygen use and equipment management. An LPN confirmed the absence of labeling and a care plan, acknowledging the need for both and indicating an intention to address these issues. The Director of Nursing was informed of the missing care plan for the resident's oxygen use.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
The facility failed to properly label the oxygen tubing with the date it was last changed for a resident, leading to a deficiency in infection control practices. Resident #261, who is [AGE] years old, was admitted with chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, and emphysema. Observations on two consecutive days revealed that the oxygen tubing on the resident's concentrator was not labeled with the date of the last change, despite a physician's order to change the tubing weekly every Sunday on the night shift. A review of the medication administration record indicated that the tubing was reportedly changed on 07/14/24, but there was no label to confirm this. The facility's policy on oxygen administration, created in July 2022, requires that the oxygen delivery device be changed weekly and dated to assist with tracking. An interview with an LPN confirmed that the tubing should have been labeled and that a care plan should be in place for the resident's oxygen use. The Director of Nursing was informed of the issue, highlighting a lapse in adherence to the facility's infection control policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident admitted with a pressure injury. The resident was admitted with sepsis due to an unstageable pressure injury on the sacrum. Initial assessments and documentation of the wound were inconsistent, with discrepancies in staging and measurements. The admission assessment inaccurately recorded the wound size, and subsequent assessments varied in staging from unstageable to Stage 3, despite the presence of significant slough. The facility's policy required weekly assessments and documentation, which were not consistently followed, as evidenced by missing assessments after a certain date. The Director of Nursing (DON) confirmed the inaccuracies in the initial measurements and acknowledged the inconsistency in staging the pressure injury. The DON also noted that the facility had a past noncompliance issue related to pressure injuries but did not include this resident in the corrective actions because the focus was on injuries developed within the facility. The facility's Skin Management Program policy required weekly documentation of wound characteristics, which was not adhered to in this case, leading to the deficiency.
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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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