Corewell Health Rehab & Nursing Center-commons Far
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington Hills, Michigan.
- Location
- 21450 Archwood Circle, Farmington Hills, Michigan 48336
- CMS Provider Number
- 235462
- Inspections on file
- 24
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Corewell Health Rehab & Nursing Center-commons Far during CMS and state inspections, most recent first.
A resident sustained a fall and multiple injuries when a CNA attempted to provide care and reposition the resident without locking the bed wheels. The bed was in a high position and rolled backward as the CNA rolled the resident toward their body, causing the resident to fall to the floor and suffer a hematoma to the forehead, skin tears, bruising, and a closed displaced fracture of the left tibia, along with contusions and abrasions to the upper extremities. Facility documentation and staff statements confirmed that the unlocked bed wheels were the cause of the fall, despite a facility safety policy requiring bed wheels to be locked.
A resident with multiple neuropsychiatric diagnoses became less responsive, prompting a nurse to contact a PA who ordered STAT labs and later ordered D5% 0.45% NS IV fluids. The lab results showed a critically high blood glucose of 732, but the PA did not document reviewing these labs and still ordered continuous IV fluids containing dextrose, which nursing staff implemented and clarified over the next day. The resident remained on D5% 0.45% NS while serial nursing notes documented ongoing infusion, progressive lethargy, and repeated glucometer readings of "Hi," leading to insulin administration per NP orders and eventual EMS transfer to the hospital for high blood sugar and altered mental status. In interview, the PA stated they were unaware of the critical glucose level before ordering the dextrose-containing IV fluids, and the DON acknowledged the order could have been questioned by nursing staff, contrary to facility policy requiring provider review and analysis of abnormal labs.
Clean dessert cups were stored uncovered near a handwashing sink, and cooked pork loins were not properly cooled or logged according to FDA Food Code standards. The CDM confirmed the lapses in both storage and documentation practices.
A resident with hypertension did not receive a prescribed blood pressure medication for four days due to unavailability, and there was no documentation that the physician was notified or that alternative instructions were sought. The DON was unaware of the missed doses, and facility protocol for handling unavailable medications was not followed or documented.
A resident was repeatedly served pork products despite her stated preference to avoid pork, leading to frustration. The resident had communicated her dietary restriction, but the information was not consistently relayed or honored by dietary and nursing staff, resulting in inappropriate meal service.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Surveyors found widespread unclean conditions, including debris, food spills, and soiled curtains in resident rooms and common areas. Staff personal items were improperly stored in a resident dining area, and the Environmental Services Supervisor acknowledged that cleaning and spot checks had not been adequately performed. The facility's housekeeping policy was not available when requested.
Surveyors found that food items brought in from outside and stored in a community refrigerator were not labeled with resident identifiers or dates, as required by facility policy. An RN acknowledged that these items should have been properly labeled.
A resident with metastatic cancer, COPD, and chronic respiratory failure who tested positive for influenza A and was on antiviral therapy did not receive complete and accurate sepsis screening as required. Nursing staff failed to fully complete the Severe Sepsis Screening Tool, leaving sections blank or incorrectly documenting the resident's infection status, despite ongoing isolation precautions and antiviral treatment.
A resident with multiple respiratory diagnoses and a new order for PRN oxygen was not properly monitored, as staff failed to document oxygen saturation levels prior to oxygen administration and did not record PRN oxygen use on the MAR/TAR. The DON confirmed the lack of required documentation and absence of a facility policy for monitoring PRN oxygen therapy.
The facility failed to maintain kitchen sanitation and proper food safety practices. Gnats were found near the handwashing sink, and the walk-in cooler had improperly stored and dated food items. Cooked pork butt was not cooled correctly, and the dish and ice machines showed signs of neglect. The dry storage room and areas around the ice machine were unclean, with food debris and cobwebs present.
The facility failed to employ a qualified full-time social worker to meet residents' psychosocial, mental, and behavioral health needs. During a survey, it was found that the only social worker, Staff 'D', was not licensed, with their last license expiring in 2019. The Administrator was aware of this but believed a license was unnecessary. The facility, licensed for 179 beds, had not employed a licensed social worker since July 2024, leading to concerns about unmet resident needs.
The facility failed to implement adequate infection control practices during wound care for a resident with pressure ulcers, as Enhanced Barrier Precautions were not utilized. Additionally, staff did not adhere to proper PPE protocols for residents on droplet precautions related to COVID-19, as observed with an LPN and a CNA who did not wear the required face shield or goggles. These lapses indicate a failure to follow established infection control protocols.
The facility failed to ensure call lights were within reach for three residents, preventing them from summoning help. A resident with severe cognitive impairment had the call light out of reach on two occasions. Another resident in Covid-19 isolation had the call light on the floor, and a third resident, also in isolation, had the call light out of reach. Staff confirmed and corrected the placement upon notification.
The facility failed to follow protocols for changing code status preferences for three residents with severe cognitive impairments. Discrepancies were found in documentation, with verbal consents obtained without proper follow-up or legal verification. This led to conflicting records regarding residents' CPR preferences.
A resident with Type 2 Diabetes Mellitus received their morning insulin dose hours before breakfast, contrary to professional standards. The insulin was administered between 5:24 AM and 6:23 AM, while breakfast was served at 8:30 AM, creating a 2.5-hour gap. The facility's DON acknowledged that insulin should be given closer to mealtime, highlighting a deviation from recommended practice.
A resident with Alzheimer's disease was found with multiple bruises on both arms, but the facility failed to document or assess the cause. Despite observations of discoloration, there were no recent skin assessments or incident reports, and staff were unaware of the bruising. The DON suggested a nutritional deficiency but did not document it in a care plan.
A resident in an LTC facility was without prescription glasses since July, leading to headaches and difficulty in activities. Despite a social work note indicating the issue, the facility's social services were unaware of the resident's need for vision services. The resident was placed on an ancillary services list without a specific request for vision services, delaying necessary care.
A resident in an LTC facility developed pressure ulcers due to the facility's failure to implement preventative interventions and administer treatment as per physician's orders. Observations showed the resident's feet were not protected by pressure-relieving boots, and wound care was performed without proper pain assessment or hand hygiene. The resident's clinical record indicated the ulcers developed while in the facility, and necessary interventions were not in place until identified by a surveyor.
The facility failed to provide fresh water within reach for two residents, risking dehydration and electrolyte imbalances. One resident had a water cup out of reach despite orders for increased fluid intake, while another had a full cup of water inaccessible. Additionally, the facility did not adequately monitor a resident's significant weight loss, with no documented plan for addressing the issue. Staff interviews revealed a lack of awareness and monitoring of residents' hydration and nutritional needs, indicating a failure to implement facility policies effectively.
Two residents experienced unnecessary pain due to inadequate pain management in an LTC facility. One resident was left in distress during a shower, with staff failing to document or address the pain. Another resident was not assessed for pain before wound care, leading to visible distress during the procedure. The facility did not follow its pain management policies, resulting in significant deficiencies.
A facility failed to provide adequate social services for a resident on psychotropic medication, resulting in a deficiency in monitoring and implementing individualized treatment. The resident, with severe cognitive impairment and multiple diagnoses, exhibited behavioral symptoms, but the facility lacked a comprehensive care plan and did not update medication changes. The social worker did not include historical information in assessments and deferred responsibility to a psychiatric provider, leading to inadequate guidance for staff. The behavior committee meetings did not address the resident's needs, and the DON acknowledged the lack of documentation.
The facility failed to ensure that monthly drug regimen reviews by the consultant pharmacist were reviewed and acted upon by the medical provider for two residents. One resident experienced delays in monitoring and medication adjustments, while another resident's Lexapro dosage recommendation was not addressed in a timely manner, despite agreement from the facility provider.
A facility failed to justify the use of antipsychotic medication for a resident with dementia, as no targeted behaviors or psychotic symptoms were documented. Despite episodes of yelling and refusal of care, the facility did not attempt a gradual dose reduction or develop individualized non-pharmacological interventions. Staff interviews revealed a lack of clarity in monitoring and addressing behaviors, with no explanation for the absence of targeted interventions.
The facility failed to maintain accurate medical records for two residents regarding advance directives. One resident's current medical directive was missing from the EMR, while another's records contained conflicting documentation about code status and lacked a medical power of attorney. Staff interviews revealed inconsistencies in the facility's process for handling advance directives, contributing to the deficiencies.
Failure to Lock Bed Wheels During Repositioning Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident care area was free from accident hazards and that adequate supervision and safety practices were used during resident care, specifically by not locking the bed wheels before repositioning a resident. According to a nursing progress note, a CNA reported that while providing care, they rolled the resident toward themselves, but the bed was in a high position with the wheels unlocked and rolled backward, causing the resident to fall from the bed to the floor. The resident was found on the floor next to the bed in a curled position leaning toward the right side, with a hematoma to the forehead, a skin tear on the left deltoid, and a skin tear on the right elbow, and complained of pain to the left foot. The facility’s post-fall analysis and investigation documented that staff rolled the resident toward themselves and the bed rolled away due to unlocked wheels, which was identified as the root cause of the fall. A written statement from the CNA confirmed that while performing care and rolling the resident from the wall side toward their body, the bed slid and the resident fell onto her side, resulting in bruising to the head, arm, and leg. Hospital imaging and assessment documented a closed displaced fracture of the left tibia, a contusion of the left upper extremity, and an abrasion of the right upper extremity, with the resident made non–weight bearing on the left lower extremity. The facility’s Resident Safety and Precautions policy in effect at the time required that bed wheels be locked as part of resident safety standards, which was not followed in this incident.
Failure to Review Critical Glucose Result Before Ordering Dextrose-Containing IV Fluids
Penalty
Summary
The deficiency involves the failure of the attending provider to review and act upon critical laboratory results before ordering and continuing IV fluids containing dextrose. A resident with psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder was noted by a CNA as "wasn't herself" on the morning of 12/8/25. Nurse B contacted the on-call PA, who ordered STAT labs including a CBC and CMP. Labs drawn that morning and reported at 12:37 PM showed a critically high blood glucose level of 732 (normal 70–99). Nurse B later documented at 3:24 PM that they reviewed the lab results with the PA while the PA was in the building, and that new orders were received for D5% 0.45% NS at 125 ml/hr for 3 liters, with an IV started but then pulled out by the resident. The PA’s progress note for 12/8/25 documented an assessment of acute kidney injury and a plan to give 2 liters of IV fluid continuous, but did not document review of the STAT labs or specify the type of IV fluid. Subsequent nursing notes show that on the afternoon of 12/8/25 the PA called back with new orders for hypodermoclysis, which was initiated. On 12/9/25, Nurse G documented placement of a new PIV and that the resident was hooked up to IV fluids as ordered, specifically D5% 0.45% NS per the PA’s prior order. Nurse H documented an order clarification for D5% 0.45% NS infusing at 125 cc/hr times 2 liters, and Nurse I documented that the resident had a peripheral IV in the right forearm with D5% 0.45% NS infusing at 125 cc, bag 2 of 2. In the early hours of 12/10/25, Nurse C documented that the resident was resting in bed with D5% 0.45% NS infusing via right arm PIV, and that the resident was hard to arouse. A blood sugar check at that time read "Hi" on the glucometer, and the on-call NP was contacted. New orders were received to give 12 units of Lispro insulin, recheck in 2 hours, and repeat 12 units if the blood sugar still read "Hi," with instructions to call back if it remained "Hi" after the second dose. Subsequent notes by Nurse C documented repeated "Hi" blood sugar readings, administration of Lispro insulin, the resident being lethargic and difficult to arouse, and that an ambulance was called for transfer to the hospital. Hospital records indicated the chief complaint was high blood sugar and altered mental status, and EMS reported the patient was receiving D5 fluid hydration on their arrival. In an interview, the PA stated they were not aware of the glucose level of 732 prior to ordering D5% 0.45% NS, acknowledged they did not document lab review, and stated they would not have ordered IV fluid with dextrose if they had known. The DON indicated that the PA’s order for D5% 0.45% NS could have been questioned by the nurse who received the critical glucose result and implemented the order. The facility’s policy requires providers to review laboratory tests during visits and analyze abnormal results with documented rationale and interventions.
Improper Storage and Cooling of Food Items
Penalty
Summary
Surveyors observed that clean dessert-sized cups were stored uncovered in bins next to a handwashing sink. When questioned, the Certified Dietary Manager (CDM) acknowledged that the cups should have been covered. This storage practice did not comply with the 2022 FDA Food Code, which requires clean equipment and utensils to be stored in a clean, dry location, protected from contamination, and either covered or inverted. Additionally, two pans of whole, cooked pork loins were found on a speed rack in the food preparation area, covered with plastic wrap and dated from the previous day. The internal temperatures of the pork loins ranged from 48-51°F, and review of the facility's cooling log showed that the pork loins had not been logged to ensure proper cooling. The CDM was unsure why the cooling log was not used. This practice did not meet FDA Food Code requirements for cooling cooked food to 41°F or less within the specified timeframe.
Failure to Notify Physician and Administer Prescribed Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of hypertension did not receive a prescribed blood pressure medication, candesartan-hydrochlorothiazide, for four consecutive days following admission. The medication was not available on the medication cart or in the backup medication dispensing machine, and although it was ordered from the pharmacy, there was no follow-up or documentation indicating that the medication had been received or administered during this period. Progress notes and the Medication Administration Record confirmed the medication was not given on four specific days, and there was no documentation that the attending physician was notified of the unavailability of the medication. Interviews with the resident and the Director of Nursing (DON) revealed that the resident expressed concern about not receiving the medication and that the DON was unaware of the missed doses until after the fact. The DON stated that facility protocol required contacting the pharmacy and notifying the medical provider for further instructions or alternative orders when a medication was unavailable, but there was no evidence this occurred. The pharmacy technician also failed to communicate with the facility regarding the delay. Documentation from the physician and provider progress notes did not mention the medication's unavailability, and there was no indication that alternative measures were considered during the four-day lapse.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
A resident was observed during a lunch meal with a container of food pushed aside, stating she did not eat the meal because it contained pork, which she does not consume. The resident reported that the facility repeatedly served her pork products despite her clear communication that she did not eat pork. She also mentioned previous instances where she was served eggs mixed with pork products. The meal ticket for that day confirmed that pork tenderloin was served to her. Interviews with the Registered Dietician (RD) and the Director of Nursing (DON) revealed that dietary assessments are typically completed within seven days of admission, and any dietary preferences expressed prior to that should be communicated to both the RD and kitchen staff. The DON confirmed that nursing staff are expected to relay residents' food preferences to dietary staff. Despite these protocols, the resident's dietary preferences were not consistently honored, resulting in her frustration.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances of unclean and unsafe environmental conditions throughout the facility, including scattered straw wrappers, crumbs, and debris in hallways and resident rooms. Dried food matter was noted on walls, and partition curtains in several rooms were soiled and unkempt. In the dining areas, there were moderate-sized dried food spillages on carpets, and the carpet near the medication cart was heavily soiled. Additional observations included hardwood flooring with scattered debris and food crumbs, as well as soiled hallway carpeting with liquid spills and old food matter that appeared to have been run over by a wheel. Staff personal belongings were found improperly stored in a residential dining room cabinet, which was acknowledged by staff as inappropriate. During a tour with the Environmental Services Supervisor, the supervisor confirmed that the areas of dried food and soiled curtains should have been identified and cleaned. The supervisor also acknowledged that the resident rooms and hallways appeared cluttered with debris and had not been vacuumed for some time, despite claims of recent cleaning. The facility's policy for environment and housekeeping was requested but was not available at the time of exit. These findings indicate a failure to maintain a safe, clean, and comfortable environment for residents.
Failure to Label and Date Resident Food Items in Community Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items brought in from outside sources and stored in the community residential refrigerator in the 2107 Dayroom were properly labeled and dated. During an inspection, several food items, including a brown paper bag from a fast food restaurant, a black three-compartment container with cornbread, a small clear container with white dressing, a Styrofoam cup with a brown liquid, a container of vanilla ice cream, and another Styrofoam cup with an unidentified frozen substance, were found in the refrigerator and freezer without any resident identifiers or dates. The facility's policy requires that all food brought in for residents be labeled with the resident's name and the date it was brought in, but this procedure was not followed. The unit manager RN confirmed that the items should have been labeled accordingly.
Failure to Complete Sepsis Screening for Resident with Active Infection
Penalty
Summary
The facility failed to conduct accurate and thorough sepsis screening for a resident who was admitted with multiple serious diagnoses, including metastatic cancer, COPD, and chronic respiratory failure. The resident tested positive for influenza A and was placed on droplet precautions, receiving antiviral therapy as ordered. According to facility policy and the Infection Control Preventionist, residents with infections treated with antibiotics or antivirals are to be monitored for sepsis using a Severe Sepsis Screening Tool throughout the duration of the illness and isolation precautions. A review of the resident's sepsis screening documentation revealed that, although the presence of infection and antiviral therapy was noted on some days, the remainder of the screening tool was left incomplete, omitting required assessments for SIRS and organ dysfunction. On subsequent days, the documentation incorrectly indicated the absence of infection and therapy, despite the resident's ongoing positive influenza status and antiviral treatment. The facility's own infection control surveillance confirmed the resident had an active infection and was under isolation precautions, but the required sepsis monitoring was not properly completed or documented.
Failure to Monitor and Document PRN Oxygen Administration
Penalty
Summary
The facility failed to appropriately monitor and document the respiratory status of a resident who experienced a change in condition. The resident, who had diagnoses including influenza A, COPD, metastatic prostate cancer with bone involvement, obstructive sleep apnea, and chronic respiratory failure, was admitted without a need for oxygen therapy. After testing positive for influenza A, a physician's order was written for PRN oxygen at 2 liters for shortness of breath. However, there was no corresponding order or documentation area on the MAR/TAR for PRN oxygen, and no consistent documentation of when oxygen was administered. Throughout the resident's stay, oxygen saturation levels were recorded only while the resident was already receiving oxygen, with no documentation of oxygen saturation prior to administration. Progress notes indicated episodes of labored breathing and low oxygen saturation while on oxygen, but failed to provide information about the resident's status before oxygen was applied. The Director of Nursing confirmed that documentation of PRN oxygen administration and pre-administration oxygen levels was lacking, and the facility did not have a policy regarding monitoring respiratory status for PRN oxygen.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure potentially hazardous food items were properly cooled, as observed during a survey. Several gnats were found flying around the handwashing sink near the kitchen entry door, and the trash can for the sink lacked a liner, attracting more gnats. The presence of insects violated the 2017 FDA Food Code, which requires premises to be free of pests. Additionally, the walk-in cooler had milk pooled on the floor, an opened cooked ham past its use-by date, an undated sliced onion, and a tub of ricotta also past its use-by date. Raw turkey was improperly stored above raw beef, which could lead to cross-contamination. The facility also failed to properly cool cooked pork butt, which was tightly covered with foil and stored in the walk-in cooler without recorded temperatures on the cooling log. The internal temperature of the pork was measured between 50-53 degrees Fahrenheit, not meeting the FDA Food Code requirements for cooling potentially hazardous food. The dish machine had a heavy buildup of limescale, and the ice machine had dust and black stains, indicating a lack of proper cleaning and maintenance. In the dry storage room, the floor was observed with cobwebs, food debris, and a leaking can of soda. The area under the ice machine had debris, a juice cup, and an ice cream cup, while the floor drain in front of the ice machine had a heavy accumulation of food debris and grease. The steam table had a bin of thickener with scattered powder, a soiled toaster, and a buildup of crumbs mixed with standing water. These observations highlight the facility's failure to maintain cleanliness and adhere to the FDA Food Code standards for food safety and sanitation.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as identified during a recertification survey. The survey, conducted from October 28 to October 30, 2024, revealed multiple concerns regarding the facility's social work practices, including mood and behavior management, psychotropic medication, psychosocial assessments, and processes for completing advance directives and coordinating decision-makers. Interviews with the Director of Nursing (DON) and Staff 'D' confirmed that Staff 'D' was the only social worker employed at the facility, which is licensed for 179 beds. Staff 'D' reported that they had been working as a social worker since January 2024 but were not currently licensed, with their last license having expired in 2019. The facility's Administrator was aware of Staff 'D's lack of licensure but believed, based on advice from other facilities and their corporate team, that a license was not necessary. The Administrator confirmed that the last licensed social worker was employed until July 5, 2024, and acknowledged the difficulty in filling the social worker role. The surveyors identified concerns with the facility's hiring of a non-licensed individual for the social worker position, which could potentially lead to unmet psychosocial needs of the residents.
Inadequate Infection Control Practices in Wound Care and Droplet Precautions
Penalty
Summary
The facility failed to ensure adequate infection control practices during wound care for a resident identified as having pressure ulcers. During observations, it was noted that Enhanced Barrier Precautions (EBP) were not in place or utilized during the wound care process. The nurse involved did not wash hands or use hand sanitizer before donning gloves and proceeded to touch multiple surfaces before handling wound care supplies. Additionally, the nurse did not change gloves after touching contaminated surfaces, which compromised the aseptic technique required for wound care. In another instance, the facility did not implement proper infection control practices for residents on droplet precautions related to COVID-19. A Licensed Practical Nurse (LPN) entered a resident's room marked for droplet isolation without donning the appropriate Personal Protective Equipment (PPE), such as a gown, gloves, or face shield. The LPN acknowledged the oversight upon being questioned and subsequently donned a gown and gloves but still failed to wear a face shield or goggles as required by the facility's policy. Similarly, a Certified Nursing Assistant (CNA) entered another resident's room on droplet precautions wearing only a gown and gloves, without the necessary face shield or goggles. The CNA admitted to the oversight when questioned. The facility's policy clearly states the need for protective eyewear and respiratory protection for droplet isolation, which was not adhered to in these instances, indicating a lapse in following established infection control protocols.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were easily accessible and within reach for three residents, resulting in their inability to summon help when needed. Resident R8 was observed on two occasions with the call light out of reach, once draped across the end of the footboard and another time tucked behind the wall and mattress. R8 had severe cognitive impairment, physical behavioral symptoms, and was always incontinent of bowel and bladder. The Director of Nursing acknowledged the issue and mentioned the need for staff re-education. Resident R7 was found with the call light on the floor, several feet from the bed, while in isolation for Covid-19. R7 had moderate cognitive impairment and was diagnosed with muscle weakness and chronic obstructive pulmonary disease. Similarly, resident R333, also in isolation for Covid-19, was observed with the call light on the floor, out of reach. R333 was dependent on oxygen. In both cases, staff confirmed the call lights were out of reach and placed them within reach upon notification.
Failure to Follow Protocols for Code Status Changes
Penalty
Summary
The facility failed to adhere to appropriate protocols for changing residents' treatment preferences regarding code status, affecting three residents. Resident R32, who was admitted with Alzheimer's Disease and had a severely impaired cognition score, had conflicting documentation regarding their code status. The resident's legal guardian had signed a form indicating a preference for CPR, but a care conference note later indicated a change to DNR without evidence of the resident's involvement in the decision-making process. Resident R63, also with a diagnosis of dementia and severely impaired cognition, had discrepancies in their code status documentation. The legal guardian had signed a form indicating CPR, but the electronic medical record showed No CPR. There was no evidence that the resident was included in discussions about changing their code status, and verbal consent was obtained without a follow-up signature from the legal guardian. Resident R52, with severe cognitive impairment and functional quadriplegia, had conflicting documentation regarding their code status. The facility's records showed a lack of proper documentation for a Durable Medical Power of Attorney, and verbal consent for a DNR order was obtained from a daughter without verification of legal authority or the resident's prior wishes. The facility's process for handling advance directives was inconsistent, with verbal consents being used without proper follow-up, leading to discrepancies in residents' code status documentation.
Insulin Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure insulin administration was performed according to professional nursing standards of practice for a resident with Type 2 Diabetes Mellitus. The resident expressed concerns about receiving their breakfast tray late, around 9 AM, while their morning insulin dose was administered hours earlier, between 5:24 AM and 6:23 AM, over several days. The scheduled time for the morning insulin dose was 6 AM, but the breakfast trays were delivered at 8:30 AM, creating a gap of 2.5 hours between insulin administration and meal delivery. The resident's physician orders specified the use of Humalog KwikPen Subcutaneous Solution per sliding scale four times per day, which according to the manufacturer's guidelines, should be injected within 15 minutes before or right after a meal. The Director of Nursing confirmed that short-acting insulin should be given closer to mealtime, indicating a deviation from the recommended practice. This discrepancy between insulin administration and meal delivery times led to the deficiency identified by the surveyors.
Failure to Identify and Document Bruising in Resident
Penalty
Summary
The facility failed to identify, assess, and determine the root cause of bilateral arm bruising for a resident reviewed for skin conditions. The resident, who has Alzheimer's disease, was observed with multiple areas of discoloration on both arms, resembling bruises. Despite these observations, there was no documentation of recent skin impairments in the resident's clinical record, progress notes, or care plans. Additionally, the resident was not on any medications that would increase the risk of bruising, and no incident reports were available for the discoloration observed. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed a lack of awareness and explanation for the bruising. The DON stated that any skin impairments should be documented in weekly skin assessments or progress notes, but this was not done for the resident in question. A progress note was written after the discoloration was observed, but it lacked further assessment. The DON later suggested a possible nutritional deficiency as the cause, but this was not documented in a care plan or diagnosed by a medical provider. An incident report from four months prior noted a skin tear but did not mention any bruising.
Failure to Coordinate Timely Vision Services for Resident
Penalty
Summary
The facility failed to timely coordinate vision services for a resident who had been without prescription glasses since July. The resident, who was admitted with diagnoses including bipolar disorder, depression, and anxiety, reported to have lost their glasses prior to admission and only had reading glasses available. This situation led to the resident experiencing headaches, eye pain, and difficulties in reading television content and participating in activities like bingo. Despite the resident's intact cognition, as indicated by a perfect score on the Minimum Data Set assessment, the facility's social services were not aware of the resident's need for prescription glasses or the associated symptoms. A social work progress note from July indicated the resident's lack of prescription glasses, but no specific action for vision services was taken until the resident was placed on an ancillary services list without a specific request for vision services. Vision service providers were scheduled to visit the facility in November, but the resident's needs were not addressed in a timely manner.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to implement preventative pressure ulcer interventions and administer treatment according to physician's orders for a resident identified as R70. Observations revealed that R70 was lying in bed on a low air loss mattress with their feet tucked under a blanket, adding pressure to the tips of the feet and toes. There were no pressure-relieving boots in use or available in the room, despite orders to suspend heels while in bed. Wound care supplies were found on the bedside table, and it was unclear if the treatment had been completed as documented by Nurse G. During wound care observation, it was noted that neither Nurse N nor Nurse L assessed the resident for pain or offered pre-medication before starting the wound care. The resident exhibited signs of pain during the procedure, and it was only after the resident expressed discomfort that pain medication was offered. Additionally, the wound care was performed without proper hand hygiene, as Nurse L used the same gloves to touch multiple surfaces and then proceeded to clean the wound. The resident's clinical record indicated that the pressure ulcers developed while in the facility, with a Stage II ulcer on the coccyx and a deep tissue injury on the left great toe. The care plan included interventions such as turning and repositioning every two hours and using skilled care boots, which had been discontinued without re-implementation. Interviews with the Director of Nursing and Wound Nurse E confirmed awareness of the issues, but the necessary interventions were not observed in place until identified by the surveyor.
Deficiencies in Hydration and Nutrition Management
Penalty
Summary
The facility failed to provide fresh water at the bedside, within reach, and offer it throughout the shift for two residents, resulting in the potential for continued dehydration and electrolyte imbalances. Observations revealed that one resident had a water cup dated from the previous day, placed out of reach, and containing room temperature water. Despite multiple physician orders to encourage oral fluid intake due to dehydration and other medical conditions, the resident's care plans did not address the need for increased hydration. Another resident was observed with a full cup of water out of reach, despite care plans indicating a risk for dehydration and the need for fresh water within reach. The facility also failed to ensure accurate assessment and adequate monitoring of weight loss for another resident. This resident expressed dissatisfaction with the facility's food and reported significant weight loss. The clinical record showed a substantial weight loss over a year, but there was no documented plan for monitoring this weight loss. The resident's nutritional assessments indicated a risk for malnutrition, yet the facility's documentation did not reflect ongoing monitoring or intervention for the resident's weight loss. Interviews with staff, including the Director of Nursing and a Registered Dietician, revealed a lack of awareness and monitoring of the residents' hydration and nutritional needs. The facility's policies on water distribution and nutrition monitoring were not effectively implemented, leading to deficiencies in resident care. The observations and interviews highlighted a failure to adhere to established protocols, resulting in potential harm to the residents due to inadequate hydration and nutrition management.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, R32 and R70, leading to unnecessary pain. R32 was observed in significant distress while seated in a shower chair, yelling and crying due to pain. Despite the resident's clear expression of discomfort, the staff did not document the incident or implement new interventions to prevent future pain. The assigned nurse, LPN 'A', dismissed the resident's cries as a behavior rather than addressing the pain, and no additional measures were taken to alleviate the discomfort during showers. R70 experienced inadequate pain management during wound care. The resident was not assessed for pain or offered pre-medication before the procedure, resulting in visible and audible signs of distress. Despite the resident's cries of pain, the nurses continued the wound care without addressing the pain adequately. The facility's records showed a lack of documentation for pain management, and the care plan was not updated to include interventions for the resident's pressure ulcers until after the surveyor's observation. The facility's policies on pain assessment and management were not followed, as evidenced by the lack of timely interventions and documentation for both residents. The Director of Nursing acknowledged the issues but did not provide additional follow-up by the end of the survey. The failure to assess and manage pain effectively for R32 and R70 highlights significant deficiencies in the facility's care practices.
Failure to Provide Adequate Social Services for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to provide adequate medically related social services for a resident receiving psychotropic medication, leading to a deficiency in monitoring, identifying, and implementing individualized treatment and behavioral interventions. The resident, who was admitted with severe cognitive impairment and multiple diagnoses including psychotic disorder and dementia, exhibited physical and verbal behavioral symptoms. Despite these behaviors, the facility did not have a comprehensive care plan addressing the resident's specific behaviors or the use of antidepressant medication. The care plan was outdated and did not reflect changes in the resident's antipsychotic medication. The facility's social worker, Staff 'D', did not include historical information from the resident or family regarding mood, behaviors, and psychotropic medication in the initial assessment. Instead, they referred residents to a contracted psychiatric provider. There was a lack of follow-up from social work to address requests for evaluation, and the behavior committee documentation did not address the resident's use of antipsychotic and antidepressant medication or specific behaviors identified by nursing staff. The social worker deferred responsibility for identifying specific behaviors and interventions to the psychiatric provider, resulting in a lack of clear guidance for direct care staff. Interviews with Staff 'D' and the Director of Nursing (DON) revealed a lack of interdisciplinary communication and documentation regarding the resident's care. The behavior committee meetings did not adequately address the resident's needs, and there was no documentation of non-pharmacological interventions or specific targeted behaviors. The DON acknowledged the lack of documentation and concern but was unable to provide further explanation. This deficiency highlights a failure in the facility's processes for managing residents with complex behavioral and medication needs.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medical provider for recommendations to act upon for two residents. For one resident, the pharmacist identified irregularities in the drug regimen on three separate occasions, recommending monitoring of serum magnesium levels, a dose reduction of Protonix, and a TSH level check. However, these recommendations were not reviewed or acted upon by the medical provider in a timely manner, resulting in delayed monitoring and adjustments to the resident's medication regimen. The resident's magnesium level was checked over two months after the recommendation, the Protonix dose was reduced two months later, and the TSH level was checked three months later, which revealed an abnormally high level requiring a dosage change. For another resident, the pharmacist recommended a gradual dose reduction of Lexapro, noting the resident's hospice status but emphasizing compliance with CMS regulations. The facility provider agreed with the recommendation but noted that the patient's medications were managed by hospice. However, there was no communication from the hospice provider regarding the pharmacist's recommendation, and the Lexapro dosage remained unchanged for over two months. The Director of Nursing later indicated that hospice would evaluate the Lexapro, suggesting that the recommendation had not been addressed in a timely manner.
Failure to Justify Antipsychotic Use and Implement Interventions
Penalty
Summary
The facility failed to provide justification for the use of antipsychotic medications in a resident with dementia, identified as R37, and did not develop or implement individualized non-pharmacological interventions. R37 was observed multiple times sleeping in a wheelchair, and their clinical record showed a prescription for Rexulti, an antipsychotic medication, for dementia, agitation, and delusion. Despite a documented attempt at a gradual dose reduction (GDR) being clinically contraindicated, there was no evidence of psychotic symptoms or targeted behaviors identified in the resident's care plan or behavior management committee meeting minutes. The facility's behavior management committee failed to document targeted behaviors or symptoms for R37, and no GDR of Rexulti was attempted as previously discussed. Progress notes indicated episodes of yelling, abusive language, and refusal of care, but there was no documented evidence of psychotic symptoms. Evaluations by the consulting psychiatry provider noted that non-pharmacological interventions had not sufficiently relieved target symptoms, yet no specific target symptoms were identified, and the GDR was deemed contraindicated. Interviews with facility staff, including Social Services Staff and the Director of Nursing, revealed a lack of clarity and responsibility in monitoring behaviors and developing interventions for residents prescribed antipsychotic medications. The interdisciplinary team approach was mentioned, but there was no explanation for the absence of individualized interventions or targeted behaviors for R37. The facility's behavior committee program was supposed to address these issues, but the Director of Nursing could not explain why this was not done for R37.
Deficiency in Maintaining Accurate Medical Records for Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R28 and R52, regarding their advance directives. For R28, the facility did not have current documentation in the electronic medical record (EMR) of a medical directive regarding decisions for code status since their admission. The only available documentation was from a previous admission, and the facility's process for documenting such directives was inconsistent, as noted by Social Services staff who indicated that medical directive forms were kept in binders and not formally loaded into the EMR. For R52, the facility's records were also incomplete and conflicting. The resident's profile identified two daughters as durable power of attorney, but the available documentation was only for financial decisions and did not include medical directives. The EMR contained a physician order for no CPR, but there was no corresponding medical directive form in the EMR. Additionally, there were discrepancies in the documentation by different medical staff regarding the resident's code status, with conflicting entries by a Physician Assistant and a Physician. The facility lacked documentation of a medical power of attorney and had not declared the resident incompetent as required to activate such a power. Interviews with facility staff, including the Director of Nursing and Social Services, revealed a lack of clarity and consistency in the process for handling advance directives. The Director of Nursing acknowledged the discrepancies and the need for immediate attention. Social Services staff admitted to the absence of a medical power of attorney in the records and could not explain why verbal consent was accepted without proper verification. The facility's practice of keeping medical directive forms in binders rather than integrating them into the EMR contributed to the deficiencies in maintaining accurate and complete medical records.
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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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