Dimondale Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dimondale, Michigan.
- Location
- 4000 N Michigan Road, Dimondale, Michigan 48821
- CMS Provider Number
- 235256
- Inspections on file
- 27
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Dimondale Nursing Care Center during CMS and state inspections, most recent first.
Three residents experienced worsening and non-healing pressure ulcers due to the facility's failure to properly assess, document, and treat wounds. For one resident, an open hand wound was not documented or communicated to the physician, and sacral and trochanter wounds were misclassified as Kennedy terminal ulcers, leading to inappropriate care. Staff relied on photographs instead of in-person wound assessments, and treatment orders were not updated despite lack of healing, resulting in significant wound progression and complications.
A review of the facility's Water Management Plan revealed missing critical elements such as team member identification, system narrative, risk area identification, and reference to industry standards. Observations included discolored water in a long-unoccupied area and inadequate flushing practices, increasing the risk for waterborne pathogens.
Surveyors identified widespread failures in cleaning and maintenance, including soiled ventilation grills, contaminated privacy curtains, damaged furniture, leaking fixtures, and accumulated dust in multiple areas. Despite facility policies and a work order system, these deficiencies were not addressed, affecting 144 residents.
Multiple residents reported incidents such as being left without care, spoken to in a rude or mean manner, or having their call light hidden by staff. These allegations were not identified or reported as abuse by facility leadership, who instead classified them as customer service concerns and failed to notify the state agency as required. Interviews with staff confirmed that these incidents were not properly investigated or documented as abuse allegations.
Multiple residents reported incidents of staff verbal abuse, neglect, and rough care, including being left without oxygen, forced to remain in soiled briefs, and having call lights hidden. Facility leadership failed to identify these as abuse allegations, did not conduct investigations, did not remove staff from resident care, and did not report the incidents to the state agency as required, instead treating them as customer service issues.
A resident with diabetes and hemiplegia reported multiple missing personal items after a hospitalization, but the facility did not document, investigate, or track these grievances as required. Despite the resident involving the Ombudsman and expressing concerns, there was no record in the grievance log, no concern forms completed, and no documentation of meetings or actions taken to resolve the issue.
The facility did not ensure that residents were protected from all forms of abuse, including physical, mental, and sexual abuse, as well as neglect and physical punishment by any individual.
Staff failed to properly label and store medications, including leaving an unlabeled medication cup with multiple pills in a medication cart and leaving a medication cup unattended in a resident's room without proper assessment or authorization for self-administration. Additionally, medication refrigerator temperature logs were found to have missing entries, with no explanation provided by the infection preventionist responsible for daily review.
A resident with multiple complex medical conditions experienced a significant change in condition, including lethargy, low oxygen saturation, and low blood pressure. Despite these changes, nursing staff administered medications without verifying vital signs or notifying the physician. The required notification to PACE of the change in condition and medication changes was also not made. The resident was eventually hospitalized and placed on life support after becoming unresponsive.
A resident with multiple complex medical conditions was administered Metoprolol and Oxycodone without prior blood pressure monitoring, despite having low blood pressure and being lethargic. The nurse did not verify blood pressure or notify the physician before administering the medications. The resident became unresponsive and required emergency transfer to the hospital. Staff interviews and record reviews confirmed that blood pressure monitoring protocols and communication of changes in condition were not followed.
A resident with known CHF experienced a 44-pound weight gain over 48 days, leading to acute re-hospitalization due to exacerbation of CHF, acute pulmonary edema, and respiratory failure. The facility failed to monitor the resident's weight consistently, notify the physician of significant weight changes, or adequately address family concerns about the resident's condition. This deficiency highlights a lack of adherence to professional standards and facility policies for managing residents with complex medical conditions.
A resident experienced severe pain after a rough transfer by a CNA, leading to a dislocated hip. The facility failed to promptly assess the resident's condition or notify the physician, resulting in inadequate pain management and delayed treatment. Staff interviews revealed a lack of training on post-operative precautions and poor communication, contributing to the deficiency.
The facility failed to provide timely and appropriate care for three residents. One resident with respiratory and heart failure had to call 911 due to the facility's delay in hospital transfer. Another resident with a history of brain injury experienced a significant change in condition, with delayed hospital transfer and inadequate diabetes management. A third resident, prescribed Oxycodone, did not receive proper constipation management, despite complaints and lack of bowel movements. These deficiencies highlight lapses in care coordination and documentation.
The facility enforced an unofficial curfew requiring residents to be inside by 8:00 PM, as indicated by signs at the entrance, restricting their freedom and visiting hours. Three cognitively intact residents expressed dissatisfaction, feeling like prisoners due to the curfew. The Nursing Home Administrator was unaware of the residents' perception and acknowledged the misleading signage, indicating plans for re-education.
The facility failed to promptly address 52 grievances reported by residents over six months, including issues with wheelchair repairs, call light response times, inappropriate clothing, falls, unauthorized room entries, and dining arrangements. The grievance handling process was inadequate, with a new program lacking proper documentation and follow-up, leaving residents with unresolved concerns and dissatisfaction.
A resident was given Cipro for seven days despite a negative urine culture, indicating no bacterial infection. The physician ordered the antibiotic based on symptoms of pain and confusion, without proper documentation or justification. The Infection Control Preventionist noted the prescription did not meet McGeer criteria and reported the issue to the Medical Director.
A resident experienced a medication error rate of 28.57% when an LPN crushed medications, including Keppra and Ferrous Sulfate, against explicit 'do not crush' orders. The medications were mixed with orange juice and administered, causing the resident discomfort. Facility resources were available to prevent such errors, but they were not utilized effectively.
A resident with a complex medical history received crushed medications, including Keppra and Ferrous Sulfate, despite clear orders not to crush them. An LPN crushed these medications and mixed them with orange juice, leading to a significant medication error. The resident showed signs of discomfort during administration, and staff interviews confirmed the error and the existence of guidelines that were not followed.
The facility failed to properly store medications in one of its medication rooms, with a vaccine refrigerator found at 60 degrees, above the recommended range. An LPN and other staff were unable to locate temperature logs, indicating a lack of proper monitoring. The DON confirmed the temperature issue and planned to dispose of affected vaccines.
The facility did not display current nurse staffing information in an accessible area for residents and visitors. Observations showed that the information was posted in a staff-only area and was outdated. HR staff responsible for posting was unaware of the requirement to display current staffing in a public area.
Failure to Identify and Treat Pressure Ulcers Resulting in Worsening Wounds
Penalty
Summary
The facility failed to correctly identify, assess, and treat pressure ulcers, resulting in worsening and non-healing wounds for three residents. For one resident, there was a lack of proper documentation and assessment for a wound on the left palm, despite clear evidence of an open wound caused by hand contractures and fingernails. The Clinical Care Coordinator was unaware of the wound's occurrence or the implementation of hand carrot orders, and there was no photographic evidence or wound assessment documented. Additionally, the physician was not notified, and no change in condition form was completed for this wound. The same resident developed a sacral wound that was initially misclassified as a Kennedy terminal ulcer (KTU) rather than a pressure injury. The wound's progression, including gradual changes in size, tissue composition, and periods of improvement and regression over 16 weeks, was inconsistent with the rapid and terminal nature of KTUs. Despite the wound's non-healing status, the treatment order remained unchanged for an extended period. The resident also developed a right trochanter wound over an implanted pain pump, which similarly persisted and worsened over several weeks, eventually exposing and dislodging the device. Both wounds were managed with treatments such as AquaCell AG, but there was a lack of timely reassessment and modification of care plans in response to the wounds' progression. Interviews with staff revealed inconsistent understanding and application of wound assessment protocols. Nurses and physicians relied heavily on photographs and electronic documentation rather than in-person assessments, and wounds were not always staged or reassessed appropriately. Weekly skin assessments failed to reflect the resident's declining skin integrity, and there was a lack of communication and documentation regarding changes in condition. The misclassification of pressure injuries as KTUs led to inadequate care planning and treatment, contributing to the worsening and non-healing of the residents' wounds.
Deficient Water Management Plan and Inadequate Flushing Practices
Penalty
Summary
The facility failed to effectively create and maintain a comprehensive Water Management Plan, impacting 144 residents. Upon review, the Water Management Plan was found to be missing several critical components, including a clear definition of the current Water Management Team Members, a written narrative of the potable water supply system, identification of high-risk areas for legionella development, and reference to accepted industry standards such as ASHRAE 188 or CDC guidelines. Additionally, the facility did not follow recommended practices for flushing low-use water systems, as evidenced by the flushing logs and CDC guidance reviewed. During an environmental tour, a hand sink in an unoccupied area was observed to have discolored water for several seconds upon flushing, and it was revealed that this area had not been occupied for at least 12 years. Interviews with maintenance staff confirmed the prolonged disuse of this area, and records indicated that flushing procedures may not have been adequate to address stagnant water in these pipes. These deficiencies increased the likelihood of waterborne pathogen development, including Legionella, due to inadequate water management and maintenance practices.
Failure to Maintain Cleanliness and Physical Plant Standards
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 144 residents. During an environmental tour, multiple areas were observed to have significant cleanliness and maintenance issues. These included malodorous soiled utility rooms due to inadequate ventilation, heavily soiled return-air ventilation grills, damaged and soiled chairs at nursing stations, and privacy curtains in shower rooms contaminated with bodily fluids and human waste. Additional findings included etched and stained commode bases, soiled fans, leaking utility sink vacuum breakers, and loose or detached faucet handles in various rooms. The presence of accumulated dust and dirt on ventilation grills, PTAC unit filters, and fans was also noted throughout the facility. Interviews with the Director of Housekeeping and Laundry Services and the Director of Maintenance revealed that while there was an established work order system (TELS), there were no specific entries addressing the identified maintenance concerns in the past 60 days. A review of the facility's housekeeping policy indicated requirements for cleaning vents and replacing privacy curtains as needed, but these procedures were not followed as evidenced by the observed deficiencies. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or theft involving nine out of ten residents were properly identified, reported, and investigated as required. Multiple residents, most of whom were cognitively intact or only moderately impaired, submitted concern forms detailing incidents such as being left without oxygen, being left in soiled briefs for extended periods, being spoken to in a rude or mean manner by staff, and having requests for care ignored or delayed. In one case, a resident alleged being sex trafficked, and in another, a resident reported that a CNA hid her call light and shut her door, leaving her to call out for help. Despite these serious allegations, the facility consistently categorized the complaints as customer service issues rather than potential abuse, and did not report them to the state agency as required. Administrator interviews revealed a pattern of minimizing or reclassifying resident complaints. The administrator often asked residents whether they considered incidents to be abuse or customer service concerns, sometimes after explaining the definition of abuse to them. In several cases, the administrator documented that residents did not feel abused after these discussions, but there was no evidence that the allegations were reported to the state agency for further investigation. In some instances, the administrator or other staff provided education to the staff member involved, but did not document any investigation or reporting of the abuse allegations. The facility's failure to recognize and report these allegations as abuse was further highlighted by interviews with other staff, including the DON, who acknowledged that some incidents described on concern forms could constitute abuse or involuntary seclusion. However, there was no documentation that these concerns were reported to the state agency. The lack of proper identification, reporting, and investigation of abuse allegations represents a significant deficiency in the facility's responsibility to protect residents from abuse and to comply with mandatory reporting requirements.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to appropriately identify, investigate, and report multiple allegations of abuse involving nine out of ten residents. In each case, residents or their representatives submitted concern forms or made statements describing staff behavior that included verbal abuse, neglect, rough or rude care, and, in one instance, an allegation of sex trafficking. Despite these reports, the facility did not recognize these as abuse allegations, did not initiate investigations, and did not report the incidents to the state agency as required. The facility's responses were limited to providing staff education or discussing the incidents with the involved parties, without further protective measures or formal documentation of investigations. Several residents, including those with cognitive impairments and those who were cognitively intact, reported specific incidents such as being left without oxygen, being forced to sit in soiled briefs, being spoken to rudely or with an attitude by nursing staff, and having call lights hidden or being left unable to call for help. In some cases, residents' family members corroborated the allegations, describing repeated patterns of staff misconduct and lack of timely response to resident needs. The facility's administration consistently categorized these concerns as customer service issues rather than abuse, even when residents explicitly stated they felt abused or when the nature of the complaint met the regulatory definition of abuse or neglect. Interviews with facility leadership, including the Administrator, DON, and Unit Manager, revealed a lack of recognition of abuse allegations and a failure to follow required protocols for investigation and reporting. Staff involved in the alleged incidents were not removed from resident care duties during the review of the concerns, and there was no evidence of five-day investigation reports being submitted to the state agency. Documentation of interviews and follow-up actions was either absent or insufficient, and in some cases, staff could not recall the incidents or the education they purportedly received. The facility did not ensure the safety of residents or comply with regulatory requirements for abuse prevention and reporting.
Failure to Document, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances regarding missing personal items were promptly documented, investigated, tracked, and resolved. The resident, who was cognitively intact and admitted for long-term care with diagnoses including diabetes and hemiplegia, reported multiple missing clothing items following a recent hospitalization. Despite making multiple complaints and involving the local Ombudsman, there was no documentation of these grievances in the facility's grievance log, nor were concern forms completed. The resident expressed a lack of trust in facility staff due to previous experiences with former administration discarding his belongings without consent. Interviews with the Ombudsman and the current Nursing Home Administrator (NHA) revealed that meetings had taken place to address the missing items, but there was conflicting information regarding the resident's wishes for reimbursement or for staff to search his room. The NHA stated that no grievance was logged because the resident did not want to file a complaint, but the Ombudsman reported that the resident only objected to staff searching his room, not to reimbursement or searching laundry. By the end of the survey, there was no documentation provided to support the facility's claims, no evidence that the laundry had been searched, and no record of the meeting with the resident and Ombudsman.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from these forms of mistreatment. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Properly Label and Store Medications and Maintain Temperature Logs
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. One resident with multiple diagnoses, including diabetes and heart disease, was observed receiving an insulin injection and being offered nine oral medications in a cup. The resident declined to take the medications immediately, requesting to take them after breakfast. The LPN left the medication cup on the overbed table and exited the room, leaving the medications unattended. The resident confirmed that staff routinely left medications for her to take later, but there was no physician order, assessment, or care plan authorizing self-administration of medication for this resident. Additionally, a medication cart inspection revealed an unlabeled medication cup containing several pills intended for another resident with severe cognitive impairment. The LPN could not identify the medications or explain the lack of labeling. Furthermore, review of a medication refrigerator's temperature log showed missing entries for several days, and the infection preventionist could not account for the omissions, despite being responsible for daily review. These actions and omissions demonstrate failures in medication labeling, storage, and documentation practices.
Failure to Notify Physician and PACE of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the Program of All-Inclusive Care for the Elderly (PACE) of a significant change in condition for a resident who was admitted for respite care following a hospital stay. The resident had multiple complex diagnoses, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, kidney failure, anxiety, and depression. Despite being cognitively intact, the resident was dependent on staff for most activities of daily living. The care plan required staff to observe for signs and symptoms of respiratory distress and to report abnormal findings to the physician as needed. On the day of the incident, the resident exhibited significant changes in condition, including lethargy, low oxygen saturation, low blood pressure, and decreased responsiveness. Multiple CNAs and LPNs observed and reported these changes, such as the need for sternal rubs to awaken the resident, oxygen saturation levels as low as 54%, and blood pressure readings below 90/56. Despite these findings, the nurse on duty administered medications, including a beta-blocker and a narcotic, without verifying blood pressure or notifying the physician of the abnormal vital signs and change in condition. The physician was not notified until the resident became unresponsive, at which point emergency services were called, and the resident was transferred to the hospital. Additionally, the facility did not communicate the change in condition or medication changes to the PACE organization, as required by the service authorization. Interviews with staff and the DON confirmed that the facility was unaware of the requirement to notify PACE of changes in care or condition. Documentation was incomplete, with missing vital signs and lack of timely change of condition forms. The failure to notify the physician and PACE of the resident's deteriorating condition and medication changes resulted in the resident being hospitalized and placed on life support.
Failure to Monitor Blood Pressure Prior to Beta-Blocker Administration Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, and kidney failure, was administered Metoprolol, a beta-blocker, without prior blood pressure monitoring. The resident was admitted for respite care and was dependent on staff for most activities of daily living. On the morning of the incident, the resident was observed to be lethargic, with low blood pressure and oxygen saturation, yet the nurse proceeded to administer several medications, including Metoprolol and Oxycodone, without verifying the resident's blood pressure at the time of administration. The nurse later acknowledged that the resident's systolic blood pressure had been reported as under 90 earlier in the shift and admitted to not checking the blood pressure before giving the medication, despite knowing that Metoprolol should be held if the systolic blood pressure is less than 100. The nurse also did not notify the physician of the resident's condition or the administration of the medication under these circumstances. Other staff members reported that the resident was non-responsive, required sternal rubs to be awakened, and had poor oxygenation and color, yet these changes in condition were not communicated to the physician or the care management organization as required. The resident subsequently became unresponsive, with a heart rate of 30, respirations of 6, and oxygen saturation of 57%. Emergency services were called, and the resident was transferred to the hospital after receiving Narcan, which temporarily improved responsiveness. Interviews with staff and review of records confirmed that blood pressure monitoring protocols were not followed, abnormal vital signs were not documented or reported appropriately, and there was a lack of communication regarding changes in the resident's condition and medication administration.
Failure to Monitor and Report CHF Exacerbation Leads to Re-hospitalization
Penalty
Summary
The facility failed to adequately assess, monitor, document, and provide timely treatment for a resident with known Congestive Heart Failure (CHF), leading to significant health deterioration. The resident, a cognitively intact female with multiple diagnoses including CHF, hypertension, and chronic kidney disease, experienced a 44-pound weight gain over a period of 48 days. Despite the resident's history of CHF exacerbations and recent hospitalizations, the facility did not consistently monitor her weight or report significant weight changes to her physician as required by professional standards of practice. Observations and interviews revealed that the resident was admitted to the facility with a weight of 356 pounds, which increased to 400.4 pounds by mid-January. The facility's staff failed to notify the physician of the resident's significant weight gain, which exceeded the threshold for concern in CHF patients. Additionally, the resident's family reported concerns about her increased edema and shortness of breath to the nursing staff, but these concerns were not adequately addressed or documented. The resident was eventually sent to the hospital after family insistence, where she was diagnosed with acute exacerbation of CHF, acute pulmonary edema, and acute respiratory failure. The facility's policies and procedures for monitoring residents with CHF were not effectively implemented. Interviews with staff, including the Clinical Care Coordinator and Director of Nursing, indicated a lack of awareness and communication regarding the resident's condition and weight changes. The facility's failure to adhere to its own policies and professional standards of practice resulted in the resident's acute re-hospitalization and highlighted significant deficiencies in the care provided to residents with complex medical conditions.
Failure to Monitor and Report Changes in Resident Condition
Penalty
Summary
The facility failed to competently assess and monitor changes in condition and notify the physician of pertinent findings in a timely manner for two residents, resulting in potential and actual harm. Resident #103, a male with a history of hip surgery and other medical conditions, experienced a significant incident on 5/9/24. During a transfer by CNA D, the resident's legs were moved roughly, causing extreme pain. Despite the resident's complaints and the family's concerns, the facility did not promptly assess the resident's condition or notify the physician. The resident's pain was not adequately managed, and he went over 24 hours without pain medication. The resident's condition worsened, and he was eventually sent to the emergency room on 5/10/24, where a dislocated hip was confirmed. The facility's records showed no evidence of a STAT X-ray order on 5/10/24, and there was a delay in obtaining the X-ray results. The resident's family reported the incident as potential caregiver abuse, and the CNA involved was suspended pending investigation. The facility's investigation revealed that staff were not adequately trained on post-operative hip precautions, and the resident's pain management was insufficient. Interviews with staff and family members highlighted a lack of communication and documentation regarding the resident's increased pain and the incident. The facility's failure to assess the resident's condition promptly and notify the physician contributed to the resident's prolonged pain and subsequent hospitalization. The report indicates systemic issues in staff training, communication, and documentation, which led to the deficiency.
Failure to Provide Timely and Appropriate Care for Residents
Penalty
Summary
The facility failed to provide timely and appropriate care for Resident #11, who was admitted with multiple serious health conditions, including acute and chronic respiratory failure and heart failure. On one occasion, the resident experienced shortness of breath and requested to be transferred to the hospital. Despite the resident's request and the nurse checking his vital signs, the facility did not facilitate the transfer, leading the resident to call 911 himself. The resident was eventually admitted to the hospital with acute hypoxic respiratory failure and other complications. There was a lack of documentation from the provider who assessed the resident, which contributed to the delay in care. Resident #121, who had a history of traumatic brain injury and other complex medical conditions, experienced a significant change in condition that was not promptly addressed by the facility. The resident's Durable Power of Attorney (DPOA) reported that the facility failed to notify him of changes in the resident's care and delayed transferring the resident to the hospital despite repeated requests. The resident was eventually transferred with dangerously high blood sugar levels, indicating a failure to monitor and manage the resident's diabetes effectively. Additionally, there was a lack of documentation regarding the resident's significant weight gain and glucose monitoring, which contributed to the resident's deteriorating condition. Resident #15, who was cognitively intact and experiencing constant pain, was prescribed Oxycodone for pain management. However, the facility failed to manage the resident's constipation, a known side effect of opioid use. Despite the resident's complaints of constipation and the absence of bowel movements for several days, the facility did not initiate the bowel protocol or offer the prescribed as-needed constipation relief medications. This oversight resulted in the resident not receiving appropriate care for constipation, as confirmed by the Director of Nursing upon review of the medical records.
Facility Enforces Unofficial Curfew, Restricting Resident Freedom
Penalty
Summary
The facility failed to honor the residents' rights to self-determination by enforcing a curfew that required residents to be inside by 8:00 PM, as indicated by signs posted at the main entrance. This curfew was not communicated as a formal policy, yet it was enforced, restricting residents' freedom to go outside or have visitors beyond the specified hours. The signs also indicated visiting hours from 8:00 AM to 8:00 PM, further limiting residents' ability to interact with family and friends during evening hours. Three residents, all cognitively intact, expressed dissatisfaction with the curfew. One resident, who was receiving hospice care, reported feeling like a child and expressed concern about missing out on events like fireworks due to the curfew. Another resident, who enjoyed spending time outside, expressed a desire to sit on the patio in the evenings but was unable to do so because of the facility's rule. A third resident, who had been in the facility since 2018, reported feeling like a prisoner and mentioned instances where residents were locked out after 8:00 PM with no apparent way to alert staff to be let back in. The Nursing Home Administrator (NHA) was unaware of the residents' perception of a curfew and stated that the facility did not have official rules regarding visiting hours or a curfew for residents. The NHA acknowledged the misunderstanding caused by the posted signs and indicated plans to re-educate staff, residents, and families about the lack of such restrictions. However, the deficiency lies in the lack of communication and the misleading signage that led residents to believe they were subject to a curfew, thus infringing on their rights to self-determination.
Facility Fails to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly address grievances and concerns reported by residents during council meetings, resulting in unresolved issues and decreased quality of life for the residents. Over the past six months, 52 grievances were filed, including issues such as delayed wheelchair repairs, slow call light response times, inappropriate clothing provided to residents, falls due to slippery floors, unauthorized entry into residents' rooms, and inadequate dining arrangements due to staffing shortages. Additionally, residents reported receiving cold food, delayed meal services, and long wait times for specific meal orders. Interviews and record reviews revealed that the facility's grievance handling process was inadequate. The Executive Director in Training (EDIT) acknowledged receiving and logging concern forms but failed to demonstrate effective tracking or auditing of these concerns. A new program, the support and services form, was introduced to address grievances immediately, but it lacked proper documentation of follow-up actions, corrections, or root cause analysis. The program, initiated in the last month, did not resolve ongoing concerns, leaving residents with unmet needs and dissatisfaction.
Unnecessary Antibiotic Administration Due to Negative Urine Culture
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered Cipro, an antibiotic, despite having a negative urine culture for bacterial growth. The resident had undergone a urinalysis, which was reviewed by the physician, and although the results were negative for infection, the physician ordered Cipro to be administered for seven days based on the resident's symptoms of bladder and flank pain and confusion. There was no documentation explaining why the urinalysis was initially required, and the progress notes did not justify the use of antibiotics given the negative culture results. The Infection Control Preventionist, a registered nurse, followed up with the Nurse Practitioner who ordered the Cipro, indicating that the prescription did not meet the criteria for administration according to the McGeer criteria, which the facility used for antibiotic use. Despite this, the Nurse Practitioner justified the antibiotic use based on the resident's pain and urinalysis results. The Infection Control Preventionist reported to the Medical Director that the Nurse Practitioner was issuing antibiotic orders without proper indications for use.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by an observed error rate of 28.57% during a medication administration for one resident. The incident involved a Licensed Practical Nurse (LPN) who crushed several oral medications, including Keppra and Ferrous Sulfate, which were explicitly marked as 'do not crush' in the resident's orders and the facility's resource documents. The medications were then mixed with orange juice and administered to the resident, who displayed signs of discomfort during the process. The resident, identified as R121, had specific physician orders and pharmacy recommendations indicating that Keppra and Ferrous Sulfate should not be crushed. Despite these instructions, the LPN proceeded to crush these medications, citing the resident's preference for not taking medications in their original form. Interviews with other staff members confirmed that the facility had resources available to inform nurses about medications that should not be crushed, and the error was acknowledged by a nurse consultant who verified the orders and the mistake.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication pass task. A Licensed Practical Nurse (LPN) crushed several oral medications, including Keppra and Ferrous Sulfate, which were explicitly marked as 'do not crush' in the resident's physician orders and the facility's medication guidelines. These medications were then mixed with orange juice and administered to the resident, who displayed signs of discomfort during the administration. The resident involved was a male with a complex medical history, including traumatic brain injury, diabetes mellitus, and seizure disorder, among other conditions. The resident's Minimum Data Set (MDS) indicated a severely impaired ability to make daily decisions. Despite the pharmacist's recommendation and clear physician orders not to crush Keppra and Ferrous Sulfate, the LPN proceeded to do so, leading to a significant medication error. Interviews with facility staff confirmed the error and acknowledged the presence of resource documents that should have prevented such an occurrence.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in one of the three medication rooms reviewed, which could lead to decreased medication efficacy and adverse side effects for the residents. During an observation, an LPN reported that an RN had unlocked the south hall medication room, which contained two refrigerators. One refrigerator was designated for resident overstock medications, and the other for vaccines. Upon inspection, the vaccine refrigerator was found to have a temperature of 60 degrees, which is above the recommended range of under 40 degrees. The LPN was unable to locate the temperature log for the refrigerator, indicating a lack of proper monitoring. Further interviews revealed that the Clinical Care Coordinator and the Director of Nursing were also unaware of the location of the temperature logs, with the latter finding an incomplete log with missing entries for several days. The Director of Nursing confirmed that the vaccine refrigerator's temperature was too warm and planned to dispose of the affected vaccines. The Registered Nurse Infection Control Nurse reported that she observed the refrigerator temperatures daily from Monday to Friday and provided a log for the current month, but was unaware of the need to keep records beyond the current month, leading to the deletion of past records.
Failure to Display Current Nurse Staffing Information
Penalty
Summary
The facility failed to display current nurse staffing information in a location accessible to all 135 residents and visitors. Observations on multiple days revealed that the staffing information was posted in a staff-only area, behind doors marked with large stop signs, indicating restricted access. The posted staffing information was outdated, with the last update being from 6/10/24, despite observations occurring on subsequent days. During an interview, HR Staff Y, who had been in the position for about a month and was responsible for posting staffing information, confirmed that the postings were intended for staff review and were unaware that the information needed to be in a public area and reflect the current day's staffing.
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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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