Ely Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Allegan, Michigan.
- Location
- 1200 Ely St, Allegan, Michigan 49010
- CMS Provider Number
- 235264
- Inspections on file
- 34
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 48 (4 serious)
Citation history
Health deficiencies cited at Ely Manor during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A resident with severe cognitive impairment and multiple chronic conditions did not receive showers or baths as required by their care plan and facility policy. Documentation showed only sporadic bathing over several months, with staff confirming gaps in care and a family member reporting infrequent hygiene assistance, resulting in dissatisfaction with care.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility’s obligation to follow care plans and respect resident choices.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with cognitive impairment and a history of falls sustained a serious injury when an exposed metal bracket, intended for a footboard but left uncovered at the end of the bed, impaled her buttock. Staff confirmed that nine beds had similar exposed brackets without footboards, and maintenance records showed no inspections or repairs had been performed for these hazards.
The facility did not maintain an effective QAPI program, with missed meetings and lack of required committee members, resulting in failure to identify and address deficiencies in resident care, safety, infection control, activity provision, and abuse prevention. Key data was not collected or analyzed, and no steps were taken to address known issues such as staff communication failures related to abuse.
A resident with multiple chronic conditions and mild cognitive impairment was left on the toilet and denied assistance with hygiene and clothing changes by a CNA, who responded angrily and refused to help. The incident caused the resident emotional distress and was corroborated by staff interviews and facility records.
A resident with moderate cognitive impairment and a history of falls, who was wheelchair-bound, fell from bed and was impaled by a metal bed frame, resulting in significant injuries including a deep laceration, fracture, and blood loss. The facility's investigation report to the State Agency omitted key details about the impalement and blood loss, resulting in inaccurate reporting of the incident.
A resident with a history of surgery, dysphagia, and risk for malnutrition experienced a 12% unplanned weight loss over 11 days. Despite care plan requirements and family concerns, staff did not notify the RD or physician of the significant weight loss, and there was no documentation of further evaluation or intervention.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, resulting in a deficiency related to confidentiality and record-keeping requirements.
A resident recovering from open heart surgery with a surgical wound was not provided proper Enhanced Barrier Precautions during direct care, as a CNA assisted with toileting while wearing only gloves and not a gown, despite clear signage and orders requiring full PPE. Staff interviews confirmed the expectation for PPE use, but the care plan lacked specific EBP focus and the CNA was unaware of the resident's precaution status.
The facility failed to respond to call lights promptly, affecting two residents' dignity and quality of life. One resident, with depression and diabetes, reported long wait times, especially during meals. Another resident, with a urinary tract infection and weakness, experienced distress due to delayed responses, leading to incontinence. Staff and Resident Council Minutes confirmed ongoing issues with call light response times.
The facility did not adequately address resident council concerns about lengthy call light wait times, as documented in multiple meetings. Staff interviews confirmed resident complaints, and the Nursing Home Administrator admitted that formal grievance forms were not completed for council-wide issues, leading to ongoing dissatisfaction.
A resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom, resulting in a skin tear and knee pain. The LPN on duty assessed the resident and notified the DON and on-call provider but did not contact the emergency contact due to the early hour. The responsibility was passed to the next shift, but the RN did not make the call, believing all notifications were complete. The facility's policy required immediate notification of significant health status changes.
The facility failed to protect residents from abuse, with incidents involving staff-to-resident and resident-to-resident interactions. A CNA verbally abused a resident with cognitive impairments, while two residents with mental health issues engaged in physical altercations. Lack of supervision and staffing challenges contributed to these incidents.
The facility failed to implement its abuse policy when a resident with Alzheimer's and other conditions made physical contact with another resident with intellectual disabilities and mental health disorders. The incident was not reported to management until two days later, despite policy requirements for immediate reporting, leading to potential unreported abuse incidents.
A facility failed to implement a comprehensive care plan for a resident with multiple health issues, including Alzheimer's and a history of falls. Despite the care plan specifying the use of a concave mattress and fall mat to prevent falls, observations showed these interventions were not in place. Staff interviews confirmed the care plan's requirements, but the Director of Nursing noted that fall mats were being removed and the care plan should have been updated.
A facility failed to follow physician orders to obtain a urine sample for a resident with a history of UTIs, leading to a potential delay in treatment. The resident, experiencing hallucinations, had an order for a urinalysis with culture and sensitivity, which was not completed as indicated in the MAR. Interviews confirmed the oversight, and the lab results were not found in the medical record.
Two residents with significant health conditions did not consistently receive scheduled showers or bathing assistance, as required by their care plans. Documentation was lacking for missed showers, and staff interviews revealed inconsistencies in handling and recording refusals, leading to unmet personal hygiene needs.
The facility failed to provide consistent, meaningful activities for two residents with intellectual disabilities and mood disorders, leading to potential negative impacts on their well-being. Observations and interviews revealed insufficient activity staff and inadequate supervision in the memory care unit, resulting in limited engagement and behavioral issues among residents.
A resident with mobility issues fell during a transfer due to inadequate supervision and failure to follow the care plan, which required a two-person assist. The CNA involved did not consult the care plan and attempted the transfer alone, resulting in the resident experiencing pain in her left arm. Subsequent imaging showed no acute fracture but revealed severe osteoarthrosis.
Two residents in a LTC facility experienced emotional distress and frustration due to being placed in a locked memory care unit without prior notification. Both residents, who were cognitively intact, reported dissatisfaction with the noise level and restrictions on their freedom, leading to increased anxiety and a loss of independence. Staff interviews revealed that the residents were not adequately informed about their placement, contrary to the facility's policy on resident rights.
The facility failed to develop comprehensive care plans for two residents, leading to inconsistent care. A resident with Alzheimer's disease and a pressure ulcer lacked a care plan for heel protectors, resulting in inconsistent use. Another resident with severe cognitive impairment and a urinary catheter had no care plan for catheter management, leading to discomfort. These deficiencies were identified through observations and interviews, revealing inadequate care planning and communication.
A resident's care plan was not updated after the removal of a feeding tube, which had been discontinued over a month prior. Despite the resident's condition change, the care plan still included outdated information about tube feeding. Staff interviews confirmed the tube's removal, and the MDS Coordinator acknowledged the oversight in updating the care plan.
A resident with hand contractures did not receive appropriate interventions to prevent worsening of their condition. Despite recommendations for bilateral handrolls and passive range of motion exercises, these were not included in the care plan or EHR. Observations showed the resident without handrolls, and interviews revealed staff were unaware of the need for these devices, indicating a communication lapse.
A facility failed to provide a mechanically altered diet as ordered for a resident with dysphagia, resulting in the potential for aspiration and choking. The resident, who had a history of stroke, was observed eating non-pureed meals in her room without supervision, despite orders requiring pureed foods when eating alone. Staff interviews confirmed the dietary needs and the risk of airway compromise, but the nursing staff did not ensure the dietary department was informed to provide the correct meal consistency.
The facility was found deficient in maintaining cleanliness and proper storage. The dry storage room had improper drainage from the ice machine and cooler condensers, causing water issues. In the central supply room, items were stored on raw wood shelving and the floor, which were not cleanable surfaces. Environmental Services acknowledged the need for reorganization.
A resident with a femur fracture did not receive prescribed tramadol for pain management on the first two days after admission, leading to increased pain. The LPN responsible cited workload issues for not entering medication orders, and the pharmacy confirmed no urgent request was made for delivery. The medication was administered on the third day.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Showers/Baths per Resident Preference and Plan of Care
Penalty
Summary
The facility failed to provide showers or baths according to the resident's preference and plan of care for one resident reviewed for Activities of Daily Living (ADL) care. The resident, who had multiple diagnoses including obstructive lung disease, heart failure, anemia, depression, anxiety, venous insufficiency, diabetes, hypertension, and arthritis, was noted to have severe cognitive impairment with a BIMS score of 2, as well as behavioral symptoms such as inattention, disorganized thinking, and rejection of care. The care plan indicated the resident required substantial to maximal assistance with bathing due to functional deficits. Documentation revealed that in March, the resident received only a few showers or baths, with some refusals, and only one documented shower or bath in April. No showers or baths were documented in May prior to discharge. Interviews with facility staff confirmed that the available documentation was complete and that there were significant gaps in the provision of showers or baths, with only one documented in April and none in May. The DON acknowledged that residents should generally be offered showers or baths twice per week according to their preferences. The facility's policy required that residents receive necessary assistance to maintain hygiene, with showers or baths scheduled according to person-centered care. The lack of consistent bathing was corroborated by a family member, who reported that the resident rarely received showers or baths, leading to dissatisfaction with care.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inspect and Maintain Bed Safety Results in Resident Injury
Penalty
Summary
The facility failed to conduct routine inspections and maintenance of resident beds, specifically neglecting to address exposed metal brackets intended for footboards on nine beds. One cognitively impaired resident with a history of falls was found after a crash was heard, lying on her side with her left buttock impaled by a metal bracket at the end of her bed. The bracket, which was designed to hold a footboard, was exposed and had entered and pressed against the resident's buttock. Multiple staff interviews confirmed that these metal brackets, some with pointed tops extending upwards, had been present on beds in use for an extended period without footboards attached. The Maintenance Director acknowledged that the beds with exposed brackets had been in use since before his tenure began, and the Nursing Home Administrator was unaware of how long the beds had been in this condition. Review of facility work orders over several months showed that none of the nine beds with exposed brackets had been reported or addressed for maintenance. Staff interviews further confirmed the presence of the hazardous brackets and the lack of footboards, directly leading to the resident's injury.
Failure to Maintain Effective QAPI Program and Address Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in the inability to identify and address multiple quality deficiencies. The QAPI committee did not consistently meet as required, with missed meetings and inadequate attendance by key members such as the Infection Preventionist, Administrator, Director of Nursing, and Medical Director. The committee also failed to collect or analyze data related to critical areas, including resident change of condition, safety and maintenance of beds, infection control practices, activity provision, and abuse prevention. Sign-in sheets confirmed irregular meetings and lack of required interdisciplinary participation. As a result of these lapses, the facility did not ensure that resident treatments were completed and documented per physician orders, timely identification and assessment of changes in resident condition, proper assembly and maintenance of facility beds, implementation of infection control practices, provision of activities to meet resident needs, and maintenance of an environment free from abuse. The Nursing Home Administrator confirmed that the facility was not tracking compliance with physician notifications or care provided as ordered, and that no steps had been taken to address identified issues such as staff communication failures related to resident-to-resident abuse.
Resident Denied Dignified Care and Assistance by Staff
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with dignity and respect by refusing to assist with care needs. The resident, who had a history of depression, anxiety disorder, chronic obstructive pulmonary disease, and chronic systolic heart failure, was mildly cognitively impaired and had a care plan that emphasized the need for a trusting and non-threatening environment. On the day of the incident, the resident requested assistance from a CNA to obtain water basins for personal hygiene and to change clothes due to the warm temperature in the room. The CNA responded angrily, refused to help, and made dismissive remarks about the resident's ability to care for herself, leaving the resident on the toilet in distress. The incident was witnessed by an LPN, who found the resident crying, frustrated, and sad after the CNA left the room. The resident reported feeling unsafe and expressed concerns about not receiving necessary care. Documentation and interviews confirmed that the CNA spoke rudely, refused to assist with hygiene and clothing changes, and handled equipment in a manner that further upset the resident. The CNA denied the allegations during the investigation and was uncooperative in interviews. The facility's records and staff interviews corroborated the resident's account of being treated without dignity and respect, resulting in emotional distress.
Failure to Accurately Report Resident Impalement and Associated Injuries
Penalty
Summary
The facility failed to accurately report an incident of neglect involving an unsafe environment to the State Agency. A resident with moderate cognitive impairment, a history of falls, and limited mobility due to being wheelchair-bound, attempted to get out of bed and fell onto a metal bed frame. This resulted in a penetrating trauma, with the metal frame impaling the resident's left buttock by approximately 3-4 inches, causing significant blood loss, a comminuted fracture of the left inferior pubic ramus and ischial tuberosity, and a 4 cm laceration near the anal region. Emergency services documented the severity of the injuries, including the impalement and associated trauma. However, the facility's investigation report, authored by the Nursing Home Administrator, did not include critical details about the impalement, blood loss, or the extent of the injuries, instead only noting a fall and subsequent fracture discovered after hospital evaluation. During interviews, the administrator acknowledged that the information provided to the State Agency should have included all apparent injuries linked to the incident but was unable to explain the omission of the impalement and blood loss from the report. This resulted in inaccurate information being reported to the State Agency regarding the incident.
Failure to Notify RD and Physician of Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor the nutritional status of a resident who was at risk for malnutrition, resulting in a significant unplanned weight loss of 12% over 11 days. The resident had a history of surgical aftercare, dysphagia, and was on a mechanically altered diet, with documented difficulties in chewing and a preference for pureed foods. Despite being identified as at risk for malnutrition and having a care plan that required monitoring and notification of significant weight changes, there was no evidence that the Registered Dietitian (RD) or physician were notified of the resident's rapid weight loss. Family concerns about the resident's intake and weight loss were raised but not addressed by staff. Interviews with facility staff confirmed that the RD and physician should have been notified of the weight loss, as per facility policy, but this did not occur. The RD stated she relied on nursing management and the Certified Dietary Manager to monitor weights, but a change in staff may have led to the oversight. The Director of Nursing confirmed the lack of documentation regarding notification of the RD or physician. Review of physician notes also showed no acknowledgment or evaluation of the resident's significant weight loss during the relevant period.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a recent history of open heart surgery and a midline sternum surgical wound was not provided with proper infection control measures during personal care. The resident required Enhanced Barrier Precautions (EBP) as indicated by physician orders and signage on the resident's door, specifying the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as toileting and changing bed linens. Despite these requirements, a Certified Nursing Assistant (CNA) was observed providing direct personal care to the resident while only wearing gloves and not a gown, contrary to the EBP protocol. The CNA stated a lack of awareness regarding the resident's EBP status at the time of care and admitted to not wearing a gown during the incident. Interviews with facility staff, including the wound nurse, confirmed that the facility follows CDC guidelines for EBP and that staff are trained to recognize signage and use appropriate PPE. However, the care plan for the resident did not specifically address EBP, and the CNA did not adhere to the required infection control practices during the observed care event.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity and respond to call lights in a timely manner, affecting two residents. Resident #104, a male with depression and type 2 diabetes mellitus, reported that his call light often took a long time to be answered, particularly during meal times. His Minimum Data Set (MDS) assessment indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #105, also cognitively intact with a BIMS score of 15, reported that delayed responses to his call light sometimes resulted in him urinating in his pants, causing him distress. His diagnoses included a urinary tract infection, unsteadiness on feet, and weakness. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about long wait times for call light responses. The Resident Council Minutes from several months also documented ongoing issues with call light response times, including instances where aides turned off call lights without addressing resident needs and took excessive time to return. These findings indicate a pattern of inadequate response to resident needs, impacting their dignity and quality of life.
Plan Of Correction
Resident #104 and #105 continue to reside in the facility. Care plans have been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated staff on the Resident Rights Policy and the Call Light Policy. Staff members who have not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will complete an audit of 10 random call lights during and around mealtimes to ensure residents' needs are met in a timely manner. An audit will be completed once a week for four weeks, then once every month for three months, to ensure call lights are being answered in a timely manner. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Address Resident Council Concerns on Call Light Wait Times
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding lengthy call light wait times. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about the delays in response to call lights. The Resident Council Minutes from multiple meetings over several months documented ongoing issues with call light response times, including reports of aides turning off call lights without addressing resident issues and taking an extended time to return. The Nursing Home Administrator (NHA) acknowledged that while the activity director shared the resident council meeting minutes with the management team, a formal concern or grievance form was not completed for issues raised by the resident council as a whole. Instead, only resident-specific concerns were documented. This lack of formal documentation and tracking of resident council concerns contributed to the ongoing dissatisfaction with call light response times and the potential for resident frustration.
Plan Of Correction
No residents were identified in this citation. Residents residing in the facility have the potential to be affected by the deficient practice. The Administrator re-educated the Activities Director of the Guest/Resident Council policy and the proper use of grievance/concern forms to be used for concern resolution. The Administrator will audit resident council minutes to ensure guest/resident concerns are resolved in a timely manner and concern forms are completed appropriately. The Administrator will complete the audit monthly for four months to ensure substantial compliance. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Administrator is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to inform a resident's emergency contact of a fall in a timely manner, resulting in a delay in notification. The resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom. The fall resulted in a skin tear on the right elbow and pain in the right knee. The incident was documented by an LPN, who assessed the resident and notified the Director of Nursing and the on-call provider but did not contact the emergency contact due to the early morning hour. The LPN passed the responsibility of notifying the emergency contact to the next shift, but the RN on the following shift did not make the call, believing all necessary notifications had been made. The resident expressed a preference for family notification in such events, and the facility's policy required immediate notification of significant changes in health status. The Nursing Home Administrator confirmed that emergency contacts should be notified immediately, regardless of the time of day.
Plan Of Correction
Resident #101 continues to reside in the facility. The resident's care plan has been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated the licensed nurses of the Notification of change policy. Any licensed nurse who has not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will audit fall documentation to ensure that all appropriate parties have been notified in a timely manner. The Director of Nursing/designee will conduct the audit once a week for four weeks, then once every month for three months, to ensure appropriate parties are being notified timely. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving both staff-to-resident and resident-to-resident interactions. One incident involved a Certified Nursing Assistant (CNA) who was reported to have verbally abused a resident with cognitive impairments and Parkinson's disease by swearing at her and forcibly pushing her in a wheelchair against her will. The resident, who had severe cognitive impairment and was prone to hallucinations, was unable to recall the incident, but witnesses confirmed the abusive behavior. The CNA admitted to swearing but claimed it was an unintentional reaction to being scratched by the resident. Another incident involved two residents, both with significant cognitive and mental health issues, engaging in physical altercations. One resident with Alzheimer's disease and impulsiveness struck another resident with intellectual disabilities and schizoaffective disorder. The incident was not immediately reported to management, and the care plan for the aggressive resident was not updated to prevent future occurrences. A subsequent altercation occurred between the same residents, with one resident striking the other in the face, highlighting ongoing supervision and intervention issues. Additionally, a resident with severe intellectual disabilities and mood disorders was involved in an altercation where she was hit by another resident. The facility's investigation revealed that the activities aide was unable to intervene in time to prevent the physical contact. Observations noted a lack of supervision in common areas, contributing to the potential for resident-to-resident incidents. The facility's staffing challenges and lack of consistent supervision in the memory care unit were identified as contributing factors to these incidents.
Failure to Report Abuse Incident in a Timely Manner
Penalty
Summary
The facility failed to ensure that staff fully implemented the abuse policy for reporting an incident of abuse involving two residents. Resident #101, who has Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and a history of stroke, made physical contact with Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, schizoaffective disorder, and experiences restlessness and agitation. The incident occurred on October 19, 2024, but was not reported to management or the Administrator until October 21, 2024, when the MDS Coordinator discovered a progress note detailing the altercation. The facility's policy requires that any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source be reported immediately to the Administrator and DON. However, the incident was not reported in a timely manner, as the agency nurse who documented the progress note did not notify management. This delay in reporting resulted in the potential for incidents of abuse going undetected, unreported, or without thorough investigation, as the facility's abuse prevention policy was not fully implemented by the staff involved.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, resulting in a lack of service to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The resident, a female with Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke, was identified as being at risk for fall-related injuries due to confusion, gait/balance problems, a history of falls, incontinence, medication use, and mobility issues. Despite these risks, the care plan interventions, such as placing a fall mat next to the bed and using a concave mattress, were not implemented as observed during multiple instances. Observations revealed that the resident was frequently found lying close to the edge of the bed without the prescribed concave mattress or fall mat in place. Interviews with staff, including CNAs and the Unit Manager, confirmed that the care plan specified these interventions, but they were not being followed. The Director of Nursing acknowledged that the resident should have had a concave mattress and that the facility was in the process of removing fall mats, indicating that the care plan should have been updated accordingly.
Failure to Follow Physician Orders for Urine Sample Collection
Penalty
Summary
The facility failed to ensure that nursing staff followed physician orders to obtain a urine sample for a resident, leading to a potential delay in treatment. The resident, a female with a history of Alzheimer's disease, diabetes, and urinary tract infections, was found lying on the bathroom floor experiencing hallucinations. A physician's order was issued to obtain a urinalysis with culture and sensitivity to investigate the cause of the hallucinations, with a specific instruction not to mark the order as completed in the Medication Administration Record (MAR) until the test was performed. Upon review, it was discovered that the order was not marked as completed in the MAR, indicating that the urinalysis was not performed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the order was not executed, and the lab results were not found in the resident's medical record. This oversight resulted in a failure to adhere to the care plan, which required obtaining labs and reporting abnormal results to the physician, potentially delaying the identification and treatment of the resident's condition.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to consistently provide showers or bathing assistance to two residents, resulting in unmet personal hygiene needs. Resident #100, who has multiple health conditions including heart failure, diabetes, and COPD, was noted to have missed several scheduled showers over a 30-day period without documentation of refusal or explanation. The care plan for Resident #100 indicated a need for substantial or maximal assistance with bathing, yet records showed instances where showers were marked as not applicable without further clarification. Similarly, Resident #101, diagnosed with Alzheimer's disease, diabetes, and other chronic conditions, also experienced lapses in receiving scheduled showers. The care plan for Resident #101 required substantial assistance and documentation of any refusals, but records showed missed showers without proper documentation of refusal or leave of absence. Interviews with CNAs and the Unit Manager revealed inconsistencies in documenting refusals and a lack of follow-up when residents declined showers, contributing to the deficiency in care.
Inadequate Resident Activities and Supervision
Penalty
Summary
The facility failed to provide consistent, meaningful, person-centered activities for two residents, resulting in potential negative impacts on their psychosocial well-being. Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, and schizoaffective disorder, was not observed participating in activities or receiving one-to-one activities as outlined in her care plan. Despite interventions being in place, such as offering distractional activities and one-to-one support, the resident had limited engagement in activities over several months, with only a few days of one-to-one activities recorded. Observations revealed that the resident often requested to go for walks but was not accommodated promptly, leading to behavioral issues. Resident #104, diagnosed with anxiety, severe intellectual disabilities, and mood disorder, also did not receive adequate one-to-one activities as recommended in her care plan. The resident was observed to be agitated and vocal when left unsupervised in the day room, and her care plan interventions, such as providing a tray table to create personal space, were not consistently implemented. The resident's limited participation in activities was noted, with only a few days of one-to-one activities recorded over several months. Interviews with staff revealed that the facility had insufficient activity staff, leading to inadequate supervision and engagement of residents in the memory care unit. The Social Services Director and other staff members acknowledged the challenges in providing consistent activities due to staffing shortages and the high number of residents. The lack of consistent staff presence and engagement in the memory care unit contributed to resident-to-resident incidents and behavioral issues, highlighting the deficiency in meeting the residents' needs for meaningful activities.
Inadequate Supervision and Care Plan Implementation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and implement care plan interventions for a resident, resulting in a fall. The resident, who had a history of unsteadiness on feet, weakness, and low back pain, required substantial assistance with mobility due to her condition. The care plan specified that the resident needed a two-person assist for transfers, but this was not followed during the incident. On the day of the incident, a CNA attempted to transfer the resident from her wheelchair to her bed without the required assistance. The CNA mistakenly believed the resident was a one-person assist and did not consult the care plan. During the transfer, the resident became weak and fell into the bed, resulting in pain in her left upper arm. An x-ray suggested a possible fracture, but a subsequent CT scan revealed no acute fracture, though it did show severe osteoarthrosis and potential chronic issues. Interviews with staff revealed that the CNA did not use a gait belt properly and was not aware of the resident's care plan requirements. The CNA was responding to a call light and did not perform a formal assessment of the resident's needs. The incident was not initially considered a fall by the LPN who assisted afterward, and no immediate pain was reported by the resident until the following day.
Failure to Provide Homelike Environment and Autonomy
Penalty
Summary
The facility failed to provide a homelike environment that promoted autonomy for two residents, resulting in emotional distress and frustration. Resident #334, who was cognitively intact and had a history of major depressive disorder and generalized anxiety disorder, was placed in a locked memory care unit without prior notification. This placement led to increased anxiety and dissatisfaction due to the noise level and restrictions on her freedom to move around the facility. Despite being promised that the unit would be converted to a regular hall, this change had not occurred, leaving Resident #334 feeling trapped and unable to participate in activities of interest. Similarly, Resident #333, who was also cognitively intact and had a history of major depressive disorder and anxiety disorder, expressed dissatisfaction with being placed in the locked memory care unit. She felt a loss of control over her life and was unable to move freely around the facility or access the courtyard without assistance. This situation led to feelings of being overly supervised and a loss of independence, contributing to her anxiety and depression. Both residents were not informed prior to their admission that they would be placed in a locked unit, which they found distressing and contrary to their preferences for independence. Interviews with staff, including CNAs, the Admissions Director, and the Nursing Home Administrator, revealed that the residents were not adequately informed about their placement in the locked memory care unit. The facility's policy on resident rights emphasizes the importance of informing residents about their rights and the rules governing their stay, which was not adhered to in this case. The lack of communication and failure to provide a suitable environment for these residents led to significant emotional distress and a feeling of confinement, highlighting a deficiency in the facility's care and communication practices.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident #34, diagnosed with Alzheimer's disease, was observed without heel protectors on multiple occasions despite having a pressure ulcer on her left heel. The care plan for Resident #34 did not include any focus, goals, or interventions related to her heel wound or the use of heel protectors. Interviews with staff, including a CNA, Unit Manager, and Hospice Nurse, revealed a lack of clarity and communication regarding the care plan for Resident #34, resulting in inconsistent application of necessary pressure-relieving devices. Resident #332, who was admitted with severe cognitive impairment and a history of urinary issues, also had an incomplete care plan. Although a urinary catheter was ordered for Resident #332, the care plan did not include any management strategies for the catheter, such as hygiene, positioning, or monitoring. An incident was reported where Resident #332 experienced discomfort due to lying on the catheter tubing, which was not addressed in the care plan. The lack of a comprehensive care plan for Resident #332's catheter care led to potential complications and discomfort for the resident. The deficiencies in care planning for both residents were identified through observations, interviews, and record reviews. The facility's failure to update and implement care plans in response to the residents' changing needs and conditions resulted in inadequate care and potential harm. The Director of Nursing acknowledged the expectation for care plans to be developed for new pressure ulcers and other significant changes in residents' conditions, highlighting the oversight in these cases.
Failure to Update Care Plan After Feeding Tube Removal
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a significant change in condition, specifically the removal of a feeding tube. The resident, who had a history of stroke with left-sided weakness and dysphagia, was initially assessed as cognitively intact and had a care plan that included tube feeding. However, the feeding tube was accidentally dislodged and subsequently discontinued over a month prior to the survey, yet the care plan was not updated to reflect this change. Interviews with staff, including an LPN and the Unit Manager, confirmed that the feeding tube had been removed and was not replaced. Despite this, the care plan still contained outdated information regarding tube feeding. The MDS Coordinator acknowledged that the care plan should have been revised to remove the tube feeding information, as care plans are meant to be updated with any changes in a resident's condition to ensure accurate and effective care.
Failure to Implement Interventions for Hand Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent the worsening of contractures in a resident with right and left hand contractures. The resident was admitted with these conditions, but the current care plan did not include any focus or interventions for managing the contractures. Additionally, there were no active physician orders in place for the resident's hand contractures. An occupational therapy discharge summary recommended the use of bilateral handrolls and passive range of motion exercises, but these recommendations were not reflected in the resident's electronic health record (EHR). Observations over several days revealed that the resident was not wearing handrolls or any other devices to prevent a decline in range of motion. Interviews with the rehabilitation director, registered nurse, certified nursing assistants, and licensed practical nurse unit manager indicated a lack of awareness and communication regarding the resident's need for handrolls. The rehabilitation director stated that the order for handrolls was communicated to the nursing team, but it was not entered into the EHR. Consequently, the nursing staff and CNAs were unaware of the requirement for the resident to wear handrolls, leading to the deficiency in care.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to provide a mechanically altered diet as ordered for a resident with a history of stroke, muscle weakness, and dysphagia, which resulted in the potential for aspiration and choking. The resident was observed eating in her room without supervision, contrary to her dietary orders that required pureed foods if she chose to eat alone. On two separate occasions, the resident was served non-pureed meals, including a taco salad and chocolate cake for lunch, and scrambled eggs and toast for breakfast, without any staff present to supervise her. Interviews with facility staff, including a unit manager, speech therapist, and registered dietitian, confirmed the resident's dietary needs and the requirement for pureed foods when eating in her room. The staff acknowledged the resident's significant risk of airway compromise due to her condition. The dietary orders were documented in the resident's care plan and Kardex, but the nursing staff failed to ensure the dietary department was informed of the resident's location to provide the correct meal consistency.
Deficiencies in Cleanliness and Storage Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper storage in two areas: the dry storage room and the central supply storage room. During a tour, it was observed that the floor drain in the dry storage room was improperly used for draining the ice machine and walk-in cooler condensers. This misuse resulted in black lines between the floor tiles and visible water seeping from the gaps when walked on. In the central supply storage room, some shelving was made from raw wood, which was not smooth or easily cleanable. Clean and sanitary items, including catheter care equipment, ice bags, hair brushes, bottles of saline, reusable urinals, and personal protective equipment, were stored on the floor and on the raw wood surface. Environmental Services H acknowledged the need to reorganize the central supply to accommodate these items properly.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was admitted with a fracture of the right femur. The resident was prescribed tramadol, a pain medication, to be taken as needed every six hours. However, the resident did not receive the medication on the first two days following admission, resulting in increased pain. The resident's family reported the issue to the Unit Manager LPN, who assured them that the medication would be administered, but the resident still did not receive it until the third day. Interviews with staff revealed that the nurse responsible for the resident on the night of admission was unable to complete all tasks due to a heavy workload, leading to the omission of entering medication orders or contacting the pharmacy. The Unit Manager LPN acknowledged being informed of the missed medications but could not explain the delay in administration. The pharmacy confirmed that no urgent request was made to deliver the medication on the day of admission, and it was only sent on the third day.
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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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