Courtney Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bad Axe, Michigan.
- Location
- 1167 E Hopson Street, Bad Axe, Michigan 48413
- CMS Provider Number
- 235456
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Courtney Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities, intact cognition, dependence for transfers, and existing lower extremity skin issues was care planned for two-assist transfers using an Invacare electronic lift and sling, with instructions to use caution to avoid striking extremities on hard surfaces. Despite this, a nurse informed a CNA that the resident could be transferred with a two-person manual assist, and the CNA and an OT transferred the resident from a beauty shop chair to a w/c without the lift. During this transfer, the resident’s leg hit the w/c foot pedal, causing large skin tears and a hematoma to the left lower leg, which required ED evaluation and ongoing wound care, as well as increased use of PRN narcotic pain medication. The DON and administrator acknowledged that the transfer should have been performed with the electronic lift as specified in the care plan.
A resident with intact cognition and multiple medical and psychiatric diagnoses repeatedly voiced concerns, through the State Ombudsman and directly, about staff being rude, turning off call lights without returning, delaying assistance, discouraging toileting by instructing use of briefs, limiting therapy focus on transfers, and prohibiting use of a personal glucometer. The Ombudsman relayed these concerns to the NHA, and the resident reported that issues persisted and had not been resolved to her satisfaction. Staff acknowledged some complaints but did not complete grievance or concern forms, and one nurse characterized the complaints as normal behavior. The Ombudsman reported the facility did not offer to complete or provide complaint forms. The NHA confirmed that no concern forms were completed for this resident, despite a written Care Program policy requiring that all oral and written concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, investigated via IDT, logged for QA tracking, and followed up to ensure satisfaction. This failure to follow the grievance policy and formally document, investigate, and evaluate the resident’s concerns resulted in the cited deficiency.
The facility failed to manage pain effectively for two residents, leading to their verbalizations of unrelieved pain and distress. One resident with pancreatic cancer received inconsistent pain medication and inadequate assessments, while another resident with multiple health issues had no pain medication order until days after admission. The facility's pain management policy was not followed, resulting in deficiencies in care.
The facility failed to ensure timely call light responses, dignified feeding assistance, and palatable food options, leading to resident complaints. Residents experienced long wait times for call light responses, inadequate feeding assistance, and dissatisfaction with food quality and availability. Additionally, the dining room was closed on weekends due to staffing shortages, and residents faced restrictions on going outside.
The facility failed to provide a clean, comfortable, and homelike environment, with observations of damaged walls, unsanitary conditions, and unsafe storage of personal items. A resident reported unfulfilled repair promises, and a CNA acknowledged unsafe storage of an electric shaver due to a low battery.
A facility failed to follow professional standards during medication administration for two residents. One resident was left unsupervised during nebulizer treatments, and necessary assessments were not performed. Another resident was left alone with medications, which they consumed without supervision, despite not having a care plan for self-administration. The facility's policies were not adhered to, resulting in these deficiencies.
The facility experienced significant staffing shortages due to the resignation of several nurses, leading to extended work hours for remaining staff. This resulted in delayed call light responses, unmet care needs, and late medication administration. Residents reported long wait times for assistance and dissatisfaction with meal service due to insufficient staffing. Nurses were observed working beyond their shifts, and medications were administered late, impacting the quality of care provided.
A facility experienced a 33% medication error rate due to late administration and unavailable medications. Errors included a resident not receiving Fenofibrate and Diclofenac Gel, another receiving medications late, and improper insulin syringe handling. Staff working overtime and poor communication contributed to the issues.
The facility failed to ensure proper infection prevention and control practices, with inadequate surveillance and documentation of infectious illnesses. Incorrect precaution signage for a resident with MSSA was observed, and infection surveillance was limited to residents on antibiotics. PPE was not consistently used, and personal items in shared bathrooms were unlabeled. In the kitchen, hairnets were not readily accessible, posing a risk of contamination. These deficiencies highlight significant lapses in infection prevention and control practices.
The facility failed to ensure proper documentation of advance directives for two residents with severe cognitive impairment. Both residents had discrepancies between their documented code statuses and their DNR orders, as the necessary signatures from legal representatives were missing. This oversight could result in the residents receiving unwanted life-sustaining treatment.
The facility failed to maintain comprehensive and updated care plans for residents, leading to deficiencies in care. A resident ambulated unassisted without proper footwear or devices, another had a pacemaker machine unaddressed in their care plan, and a third had discrepancies in their code status documentation. Additionally, a resident suffered skin injuries from a broken chair, with no proper documentation or care plan updates.
The facility failed to provide adequate ADL care for two residents, resulting in deficiencies in personal hygiene. A resident with dementia was found with unclean nails despite needing assistance with all ADLs. Another resident, who requires substantial assistance, did not receive a scheduled shower and was incorrectly marked as having refused it. The facility's policy on handling refusals was not followed, and there was no documentation of a plan to address the missed care.
The facility failed to provide adequate supervision and follow safety care plans for residents at risk of falls, resulting in potential harm. One resident was observed walking unsteadily without supervision, while another had multiple falls with injuries. Additionally, a resident's complaint about a broken chair causing cuts was not addressed, leading to a lack of timely assessment and treatment. The facility's policies on fall management and skin care were not effectively implemented.
The facility failed to provide timely and appropriate care for residents with urostomy appliances and urinary catheters. A resident with a urostomy did not have their appliance changed as ordered, and another resident had a Foley catheter left in without a physician's order after a 24-hour urine collection. These deficiencies highlight lapses in care processes and documentation.
A resident with complex medical conditions, including diabetes and end-stage kidney disease, experienced significant weight loss due to the facility's failure to assess and address nutritional needs. The resident's care plan was incomplete, and the Registered Dietitian had not conducted a timely assessment, resulting in a lack of interventions to promote nutrition. The resident was eventually transferred to the hospital due to a change in condition.
The facility failed to communicate dialysis center orders to the practitioner for two residents, leading to missed medication orders and unfulfilled diagnostic test requests. A resident did not receive a recommended medication, and another resident's 24-hour urine collection was not completed as requested by the dialysis center. These communication lapses posed risks to the residents' dialysis care.
The facility failed to ensure proper narcotic medication reconciliation and timely administration of medications. Nurses exchanged medication cart keys without completing narcotic counts, leading to potential medication/narcotic diversion. Several residents did not receive their medications as scheduled, with discrepancies in administration records. The DON acknowledged the issues, noting that the facility's policies on medication administration and controlled substances were not followed.
The facility failed to provide adequate healthy snack options, leading to resident complaints about the lack of fresh fruits and vegetables, and the repetitive nature of meals. Observations showed limited snack availability in kitchenettes, and interviews with staff confirmed the inconsistency between the facility's snack list and actual offerings.
Failure to Follow Care-Planned Lift Transfer Resulting in Leg Lacerations
Penalty
Summary
The deficiency involves the facility’s failure to implement required transfer interventions and ensure a safe environment for a resident who was care planned for use of an electronic lift. The resident had multiple diagnoses including heart failure, history of falls, chronic kidney disease, prior stroke, hypertension, hypothyroidism, atrial fibrillation, arthritis, asthma, and left leg pain. An MDS assessment showed the resident had intact cognition (BIMS 15/15), required assistance with all care, and was dependent for transfers. The care plan documented that the resident had a functional ability deficit requiring assistance with self-care and mobility related to weakness, impaired mobility, pain, and poor endurance, and specified that transfers were to be done with a two-assist Invacare electronic lift and large sling. The care plan also identified actual skin integrity impairment, including lacerations/skin tears to both lower extremities, and directed staff to use caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces. On the date of the incident, an incident report completed by a nurse indicated that the resident was being transferred from a beauty shop chair to a wheelchair by an OT and a CNA. The nurse documented that she believed the resident was care planned as a two-assist transfer “as needed,” but the resident was actually care planned as a lift transfer at all times. During this manual two-person transfer without the electronic lift, the resident’s leg struck the wheelchair foot pedal, causing three large skin tears on the left leg with significant bleeding. Progress notes described a skin tear to the left lateral upper leg with a skin flap that initially was not approximated, approximately 8 cm in size, and a second open injury of about 10 cm distal to the first, with bleeding difficult to control. The resident was noted to be on Eliquis and aspirin, and pressure dressings were applied before the resident was sent to the emergency department for evaluation. The hospital emergency department report documented an ISTAP type 3 skin tear of the left lower leg with total flap loss, an additional skin tear of the left lower leg, a hematoma of the left lower leg, and current long-term anticoagulation use. Subsequent facility documentation showed ongoing wound treatment orders for the left leg laceration and increased use of PRN narcotic pain medication after the injury. In interviews, the DON confirmed that two staff transferred the resident from the beauty shop chair to the wheelchair and that they were supposed to use an electronic lift per the resident’s plan of care. The administrator stated that the nurse assigned to the resident had told the CNA that the resident could be transferred with a two-person assist without the Invacare lift, and the CNA then obtained help from the OT to perform the transfer, during which the resident’s leg was injured on the wheelchair foot pedal. The facility’s Fall Management policy stated that hazards and resident risk factors would be identified and interventions implemented to minimize falls and related injuries, with a plan of care developed and implemented based on this evaluation.
Failure to Follow Grievance Policy and Address Resident’s Ongoing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and properly address a cognitively intact resident’s concerns that were voiced through the State Ombudsman. The resident was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, depression, anxiety disorder, paranoid personality disorder, and post‑traumatic stress disorder, and had a BIMS score of 15/15, indicating intact cognition. Functionally, the resident required varying levels of assistance with ADLs, including dependence for toileting hygiene and transfers. During an Ombudsman visit, an Elder Advocate witnessed staff responding inappropriately to the resident’s call light, including shutting off the call light, stating they were too busy, rolling their eyes, raising their voices, leaving, and not returning to assist. These concerns were relayed by the Ombudsman to the Administrator via email. In subsequent interviews, the resident reported that these issues had not been resolved and that problems with staff response to call lights and staff behavior continued. The resident described staff answering the call light and telling her they were taking care of other people, turning off the call light and not returning, instructing her to go in her brief and stating they would come back, and not returning. The resident also reported concerns about therapy not working enough on transfers to the toilet/bedside commode and being told she could not keep her own glucometer at the facility. The resident stated she preferred to communicate concerns through the Ombudsman rather than directly to the Administrator, DON, or Unit Manager, and reported that staff had not offered to help her write a concern form, had not provided her with concern or grievance forms, and had not given her any written documentation or resolutions related to the concerns she raised through the Ombudsman. Staff interviews showed that the facility did not document or process these concerns in accordance with its written Care Program grievance policy. Nursing staff acknowledged awareness of some issues, such as dressing changes, therapy participation, and behavioral concerns, but reported they had not completed grievance or concern forms, with one nurse characterizing the resident’s complaints as normal behavior and personality. The Ombudsman reported that the facility had not offered to write out a complaint form or Visitor Assistance Form and was not aware that any such forms had been completed or offered as an option. The Administrator confirmed that no concern forms had been completed for this resident’s issues, explaining that concerns were being addressed in real time and were not considered ongoing, despite the policy requiring that oral concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, discussed in IDT, logged, and followed up to ensure satisfaction. As a result of not following the policy, the resident’s concerns were not formally documented, investigated, tracked, or evaluated for satisfaction as required by the facility’s Care Program. The facility’s Care Program policy specifies that any concern or grievance, whether written or oral, should be documented on the Resident, Family, Employee and Visitor Assistance Form, acknowledged, investigated, discussed in IDT, and forwarded to the Administrator for logging and tracking in the facility’s QA log, with follow‑up within seven days to ensure the concern is addressed to the complainant’s satisfaction. In this case, the resident’s concerns communicated through the Ombudsman and directly to staff were not processed through this formal mechanism. The lack of documentation and use of the required forms meant that the concerns were not entered into the facility’s tracking and trending system, not formally investigated through the IDT process, and not subject to the required follow‑up evaluation for satisfaction, as described in the policy. This failure to follow the established grievance procedure led to the cited deficiency related to honoring the resident’s right to voice grievances and ensuring prompt, documented efforts to resolve them.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to adequately assess, monitor, and manage pain for two residents, resulting in their verbalizations of unrelieved pain, frustration, and helplessness. Resident #138, who was admitted with multiple serious health conditions including pancreatic cancer and pressure ulcers, was observed moaning loudly and expressing discomfort. Despite having orders for pain medications such as Oxycodone and Morphine, the administration of these medications was inconsistent, and pain assessments were not conducted during the day when the resident was experiencing significant pain. The care plans for Resident #138 were not followed, and the interventions specified were not implemented effectively. Resident #139, admitted with acute respiratory failure, COPD, and other serious conditions, was also observed repeatedly yelling for help and moaning. The resident had no pain medication order until several days after admission, despite exhibiting signs of discomfort and having fallen twice. Pain assessments were infrequent and mostly conducted during night shifts, with little documentation of the resident's discomfort during the day. The care plan for Resident #139 lacked sufficient interventions to address the resident's pain and discomfort. The facility's policy on pain management was not adhered to, as evidenced by the lack of timely and appropriate pain assessments and interventions for both residents. The failure to manage pain effectively led to the residents experiencing unrelieved pain and distress, highlighting deficiencies in the facility's pain management practices.
Deficiencies in Resident Care and Services
Penalty
Summary
The facility failed to ensure timely and dignified responses to call lights, proper assistance with feeding, and the provision of palatable food options, which led to multiple resident complaints. Residents reported that call lights were often not answered promptly, with some waiting up to two hours for assistance, resulting in delayed care and discomfort. Additionally, call lights were not always placed within reach, particularly for residents with limited mobility or cognitive impairments, further exacerbating the issue. The facility also did not provide assistance with feeding in a dignified manner. Observations revealed that some residents were left to eat without proper supervision or assistance, leading to difficulties in consuming their meals. In one instance, a staff member was observed standing while feeding a resident, which was deemed undignified. Furthermore, residents expressed dissatisfaction with the food served, citing a lack of fresh fruits and vegetables, and meals often being served at an undesirable temperature. The dining room was also closed on weekends due to staffing shortages, forcing residents to eat in their rooms where food was often cold. Residents expressed frustration over their inability to go outside freely, as doors were frequently locked, and the dining room closure on weekends due to low staffing levels. These issues, combined with the inadequate response to call lights and poor meal quality, contributed to a decreased quality of life for the residents. The facility's policies on resident rights and call light response were not adhered to, as evidenced by the numerous complaints and observations made during the survey.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and unclean conditions in resident rooms. On several occasions, surveyors observed large gouges and holes in the walls of resident rooms, with one resident expressing that repairs had been promised but not completed since the beginning of the year. Additionally, chipped drywall was noted in multiple rooms, indicating a lack of timely maintenance and repair. Further observations revealed unsanitary conditions, such as a fan with a large amount of dusty buildup and a bathroom floor that was dirty and sticky with dried urine. An electric shaver was found plugged in and resting on the back of a toilet, with the cord appearing to be able to reach the toilet water, posing a potential safety hazard. Despite the facility's policy on keeping residents' personal property in a safe and convenient location, the shaver remained in this unsafe position over multiple days, and a CNA acknowledged that it was left there due to a low battery.
Medication Administration and Supervision Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of care during the administration of nebulizer treatments for a resident. The nurse prepared the nebulizer medication and instructed the resident on how to use the machine but did not stay to observe the treatment. The resident struggled to operate the nebulizer and was left unsupervised, resulting in incomplete administration of the medication. Additionally, the nurse did not perform necessary assessments such as checking lung sounds, oxygen saturation, or heart and respiratory rates before and after the treatment, as required by the facility's policy. Another deficiency was observed in the supervision of medication administration for a different resident. The resident was left alone with a cup of medications, which they consumed without any staff present. The nurse confirmed that they had given the medications to the resident but did not stay to ensure the medications were taken properly. The resident's care plan did not include any interventions for self-administration of oral medications, which is a requirement according to the facility's policy. Both incidents highlight a lack of adherence to the facility's policies regarding medication administration and supervision. The Director of Nursing confirmed that the residents involved did not have evaluations or care plans that allowed for self-administration of medications, and the facility's policies were not followed, leading to these deficiencies.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide timely and adequate care for residents, resulting in long call light response times, unmet care needs, and late medication administration. The report highlights that the facility experienced a shortage of nursing staff due to the simultaneous resignation of five nurses, leading to the remaining staff being mandated to work extended hours. This situation resulted in some nurses working up to 18 hours and CNAs working double shifts to cover staffing shortages. Despite recent hiring efforts, the facility continued to struggle with maintaining adequate staffing levels, impacting the quality of care provided to residents. Several residents reported issues related to insufficient staffing. One resident was observed walking unsteadily in the hallway without supervision, as the available CNA was attending to another resident. Another resident expressed dissatisfaction with the weekend staffing, noting that it took up to an hour for call lights to be answered. A resident receiving hospice services reported experiencing significant pain and discomfort, with delays in staff response times, particularly at night. These observations and resident interviews underscore the facility's inability to meet the care needs of its residents due to staffing inadequacies. The report also details issues with medication administration, where nurses were observed working beyond their shifts to cover for absent staff. Medications were administered late, with one nurse reporting 12 residents with late medications at one point. Residents also reported dissatisfaction with meal service, as staffing shortages led to meals being served in rooms rather than the dining room, resulting in cold food. Overall, the facility's staffing challenges have led to compromised care quality, with residents experiencing delays in receiving necessary assistance and services.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 33% error rate during the survey. This was observed through 23 medication errors involving four residents out of 69 opportunities. The errors included medications not being administered on time, medications not being available, and improper medication administration practices. For instance, Resident #82 did not receive Fenofibrate and Diclofenac Gel as scheduled due to the medications not being available from the pharmacy. Additionally, the insulin syringe was improperly recapped by Nurse S, despite having a guard to cover the needle. Other residents experienced similar issues. Resident #78 received eight out of eleven medications late, and Resident #34 did not receive her nasal spray and inhaler on time, despite them being marked as administered in the system. Resident #75 received ten medications late and did not receive Miralax. The errors were attributed to staff working overtime and improper medication administration practices, such as one nurse preparing medications while another administered them, leading to confusion and delays. The Director of Nursing acknowledged the issues, noting that medications were not available and that there was a lack of communication between shifts regarding medication administration.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by inadequate surveillance and documentation of infectious illnesses among residents. The Infection Prevention and Control (IPC) Nurse was unaware of incorrect precaution signage for a resident with Methicillin Sensitive Staphylococcus Aureus (MSSA), which was mistakenly documented as Methicillin Resistant Staphylococcus Aureus (MRSA) by another nurse. This error led to inappropriate contact precautions being applied. Additionally, the facility's infection surveillance was limited to residents on antibiotics, lacking comprehensive tracking of signs and symptoms of infections, which could potentially lead to an outbreak. Observations revealed multiple instances of non-compliance with infection control protocols. Personal Protective Equipment (PPE) was not consistently used by staff when required, and hand hygiene was not performed in several instances. Personal items in shared bathrooms were unlabeled, increasing the risk of cross-contamination among residents. Furthermore, the facility's documentation of infections lacked detailed information on infectious organisms, making it difficult to track and analyze potential spread. In the kitchen, hairnets were not readily accessible, and staff had to cross clean food preparation areas without hairnets to retrieve them from a chemical storage room, posing a risk of contamination. The facility lacked a policy for hairnet use and storage, and the hand hygiene policy was not effectively implemented. These deficiencies highlight significant lapses in the facility's infection prevention and control practices, which could result in exposure to infectious organisms and an outbreak of illnesses.
Failure to Properly Document Advance Directives
Penalty
Summary
The facility failed to properly follow up on advance directives for two residents, resulting in discrepancies between documented code statuses and the residents' wishes. Resident #47 was admitted with severe cognitive impairment and had a Do-Not-Resuscitate (DNR) order signed by a physician, but the Power of Attorney (POA) did not sign the DNR form. The resident's care plan incorrectly indicated a full code status, which was not updated to reflect the DNR order. This lack of proper documentation and follow-up could lead to the resident receiving life-sustaining treatment against their wishes. Similarly, Resident #71, who also had severe cognitive impairment, had a DNR order documented in their medical record. However, the DNR form lacked a signature from the legal healthcare decision maker, and only verbal consent was noted with witness signatures from two nurses. The Director of Nursing (DON) was uncertain about the validity period of verbal authorization and confirmed the discrepancy in the code status documentation. The facility's policy on advance directives emphasizes the importance of obtaining and documenting the necessary signatures for DNR orders, especially for residents unable to make medical decisions. Despite this policy, the facility did not ensure that the DNR forms for both residents were properly signed by the appropriate legal representatives, leading to inconsistencies in the residents' care plans and potential violations of their rights to refuse treatment.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to ensure comprehensive and revised care plans for several residents, leading to various deficiencies. Resident #26 was observed ambulating unassisted and without proper footwear or assistive devices, despite having a history of falls and requiring assistance with activities of daily living. The care plan and Kardex for this resident did not specify the level of assistance needed for ambulation and transfers, indicating a lack of proper documentation and planning for the resident's mobility needs. Resident #53 had a pacemaker machine at their bedside, but the care plan did not mention this device or provide any instructions related to its management. The resident was unsure of their cardiologist's name and indicated that their spouse had the necessary information. This oversight in the care plan could lead to inadequate management of the resident's cardiac condition, as the care plan failed to address the presence and use of the pacemaker machine. Resident #47's care plan contained discrepancies regarding their code status. Although a DNR order was signed by a physician, the care plan still listed the resident as a full code, and there was no follow-up signature from the POA. This inconsistency could result in the resident receiving life-sustaining treatment against their wishes. Additionally, Resident #68 experienced skin integrity issues due to a broken chair, which led to cuts on their forearm. The facility failed to document the incident, assess the wound, or update the care plan to address the resident's skin impairment, highlighting a lack of proper wound management and documentation practices.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, resulting in deficiencies in personal hygiene and care. Resident #74, who has diagnoses including dementia, heart failure, and kidney disease, was observed with a large amount of brown residue under their right-hand nails. Despite requiring assistance with all ADLs, including personal hygiene, the resident's nails were not cleaned until after the issue was observed and brought to the attention of a CNA. The facility's records indicated that the resident's fingernails should be kept trimmed and clean, but this was not adhered to until after the observation. Resident #23, who has chronic kidney disease, muscle weakness, and requires substantial assistance with personal care, reported not receiving a scheduled shower. The resident, who has intact cognition, expressed frustration over being marked as having refused a shower, which they denied. The facility's policy requires staff to offer care three times and notify a nurse if a resident refuses, but there was no documentation of such a process or a plan for the refusal. The Director of Nursing confirmed that showers could be rescheduled according to resident preference, but this was not done for Resident #23.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure proper supervision and adherence to safety care plans for residents at risk of falls, leading to potential harm. One resident was observed walking unsteadily in the hallway without supervision, as the staff was occupied with other duties. This resident had a history of falls and required supervision and a wheelchair for safe ambulation. Another resident was also seen walking unsteadily without assistance, and the housekeeping staff had to intervene. This resident had multiple previous falls, some resulting in injuries, and was not wearing gripper socks as required by their care plan. Additionally, the facility did not adequately address a resident's complaint about a broken chair, which resulted in cuts on the resident's forearm. The resident had reported the issue more than a week prior, but no action was taken to replace the chair or assess the injury. When the resident's bleeding arm was finally noticed, there was no documentation of an assessment, incident report, or treatment order until the following day. The facility's skin management policy was not followed, as there was no ongoing monitoring or evaluation of the resident's wound. The facility's fall management policy, which requires identifying hazards and implementing interventions to minimize falls, was not effectively implemented. The staff was unable to provide adequate supervision due to being understaffed, and the care plans for residents at risk of falls were not consistently followed. The lack of documentation and timely response to the resident's injury from the broken chair further highlights the facility's failure to adhere to its policies and ensure resident safety.
Deficiencies in Urostomy and Catheter Care
Penalty
Summary
The facility failed to ensure timely and appropriate care for residents with urostomy appliances and urinary catheters, leading to deficiencies in care. Resident #26, who was admitted with a urostomy, did not have their ostomy appliance changed according to the physician's orders from the time of admission through several months. The treatment administration records showed missed appliance changes, and the resident was observed reinforcing their ostomy barrier with tape brought from home, indicating unmet care needs. The care plan did not reflect the resident's involvement in their own care or the use of home-brought materials, which could lead to potential complications. Resident #23, who had a Foley catheter for a 24-hour urine collection, did not have a physician's order to leave the catheter in place after the collection was completed. The resident reported that the catheter was left in due to a lost urine specimen and the desire to wait for results. The Director of Nursing confirmed that there was no order to continue the catheter, and the physician had not been notified. This oversight resulted in the catheter remaining in place without proper authorization or documentation, which could lead to further complications. The facility's failure to adhere to physician orders and ensure proper documentation and communication regarding residents' care needs resulted in deficiencies. The lack of timely urostomy appliance changes and the unauthorized continuation of a urinary catheter highlight significant lapses in the facility's care processes, potentially impacting the residents' health and well-being.
Failure to Assess and Address Nutritional Needs
Penalty
Summary
The facility failed to assess, monitor, and implement interventions to promote nutrition and prevent weight loss for a resident, resulting in a lack of nutritional assessments to identify the resident's needs. The resident, who was admitted with multiple complex medical conditions including diabetes, end-stage kidney disease, and pressure ulcers, was observed not eating and expressing a desire for his meal tray not to be taken away. Despite these observations, the resident's nutritional care plan was blank, and no specific interventions were in place to address his nutritional needs. The resident's food intake documentation showed minimal consumption since admission, with several meals marked as refused or not available. The resident experienced a significant weight loss of 10 pounds within five days of admission. The Registered Dietitian, who was responsible for nutritional assessments, had not yet assessed the resident due to prioritizing other residents admitted earlier. Consequently, the resident's nutritional needs were not identified or addressed, and no additional dietary notes or interventions were documented. Interviews with facility staff, including the Registered Dietitian and the Unit Manager, revealed a lack of communication and timely assessment of the resident's nutritional status. The facility's policy required a comprehensive nutritional evaluation within five days of admission, which was not completed for the resident. The Registered Dietitian acknowledged not being aware of the resident's food intake or weight loss and had not reviewed the resident's care plan, which remained incomplete. The resident was eventually transferred to the hospital due to a change in condition, highlighting the severity of the oversight in nutritional care.
Communication Failures in Dialysis Care Orders
Penalty
Summary
The facility failed to ensure proper communication of dialysis center orders to the practitioner for two residents requiring dialysis care. For Resident #23, the dialysis center recommended starting Lasix 40 mg twice a day, but there was no order for this medication in the resident's medical record, nor was there documentation that the physician had been notified of this recommendation. Additionally, the resident was prescribed Vistaril for anxiety prior to dialysis, but there was no documentation indicating whether the medication was offered or administered, and the Director of Nursing (DON) acknowledged a lack of communication regarding this order. Resident #139 experienced a similar issue with communication between the dialysis center and the facility. The dialysis center requested a 24-hour urine collection to be brought to the center, but there was no physician order for this collection, and it was not completed as requested. The Unit Manager confirmed that the request was documented on the Hemodialysis Communication Form, but it was not acted upon until after the resident returned from dialysis. The resident was later transferred to the hospital due to a change in condition. These deficiencies highlight a breakdown in communication between the dialysis center and the facility, resulting in missed medication orders and unfulfilled requests for diagnostic tests. The lack of documentation and follow-through on dialysis center recommendations posed a risk to the residents' dialysis care and overall health management.
Medication Administration and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper narcotic medication reconciliation and timely administration of medications, as well as adherence to medication administration standards. During the survey, it was observed that narcotic medication reconciliation was not completed when the medication cart keys were exchanged between nurses. Nurse T and Nurse S were observed working together to administer medications, with one nurse preparing the medications and the other delivering them, which is against the facility's policy. Additionally, the narcotic count was not conducted when the keys were handed over, leading to a lack of accountability and potential medication/narcotic diversion. Several residents did not receive their medications as scheduled. Resident #82 did not receive Fenofibrate and Diclofenac Gel because the medications were not available from the pharmacy or the backup supply. Resident #78 received 11 medications, 8 of which were administered late. Resident #34 reported not receiving her nasal spray and inhaler, which were marked as given by another nurse, indicating a discrepancy in medication administration records. Resident #75 received 10 medications late and did not receive Miralax as scheduled. The Director of Nursing (DON) was informed of these issues, including the improper exchange of medication cart keys and the lack of narcotic reconciliation. The DON acknowledged that the nurse preparing the medication should also administer it, and that narcotic counts should be completed before the keys are handed over. The facility's policies on medication administration and controlled substances were not followed, resulting in 23 observed errors during the medication administration task.
Inadequate Snack Options Lead to Resident Complaints
Penalty
Summary
The facility failed to provide sufficient healthy snack choices for residents, leading to complaints from the Resident Council. Observations and interviews revealed that residents were dissatisfied with the lack of fresh greens, vegetables, and fruits, as well as the repetitive and processed nature of the meals. Residents expressed a desire for fresh items such as tomatoes and corn, and complained about the use of margarine instead of real butter and imitation cheese. The Certified Dietary Manager (CDM) acknowledged the complaints and mentioned that the facility offered celery, carrot snacks, and bananas, but lacked other fresh fruits like apples, oranges, or grapes. The CDM also noted that the kitchen staff was responsible for stocking the kitchenettes, which was done between 1:00 and 3:00 PM. Further observations of the kitchenettes on different halls showed a lack of variety and availability of snacks. For instance, the 400 hall kitchenette had limited items such as a half sandwich, cheese puffs, Doritos, and a honey bun, with no fresh fruit, string cheese, or yogurt. Similarly, the 900 hall kitchenette was missing sandwiches, cottage cheese, and string cheese. Interviews with CNAs revealed that string cheese was rarely seen in the kitchenettes. The facility's Available Snack List included a variety of items, but the actual availability in the kitchenettes did not match this list, contributing to resident dissatisfaction and complaints.
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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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