Evergreen Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Southfield, Michigan.
- Location
- 19933 West Thirteen Mile Road, Southfield, Michigan 48076
- CMS Provider Number
- 235582
- Inspections on file
- 33
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Evergreen Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident experienced a new onset of severe right foot pain and swelling after a transfer, but despite repeated complaints and inability to participate in therapy, there was no timely or thorough evaluation by a medical provider. Initial X-rays were negative, and documentation focused on chronic pain rather than the acute injury. It was only after several days and continued decline that a comprehensive assessment and further imaging revealed a comminuted avulsion fracture, confirming a delay in diagnosis and treatment.
A resident who was fully dependent for toileting and always incontinent did not receive timely incontinence care, remaining wet and soiled for approximately 11 hours despite multiple requests for assistance. Documentation for the day was incomplete, and staff confusion over assignments contributed to the lack of care, in violation of facility policy and standard care expectations.
A facility failed to obtain consent from a legally authorized representative for psychotropic medications administered to a resident with Alzheimer's and impaired cognition. Despite the resident being deemed incompetent, the facility administered Sertraline and Lorazepam without the necessary consent from the resident's DPOA-H, contrary to facility policy.
A facility failed to follow pest control procedures, resulting in a bed bug infestation affecting a resident. The issue arose when a resident's sister brought infested belongings into the facility. Despite initiating bed bug procedures, a CNA mistakenly put potentially infested clothes back on a resident after a shower, leading to bed bugs being found in the resident's hair. The resident, with a history of bipolar disorder and PTSD, experienced discomfort and required further interventions.
A resident with Alzheimer's was mistakenly taken to another resident's room by a dietary staff member, leading to an altercation where the resident was pushed out of their wheelchair. The incident highlights a failure in communication and supervision, as the staff member was unaware of room assignments and did not consult nursing staff, resulting in a violation of the facility's abuse policy.
A resident was found covered in dry feces, and the facility failed to report the neglect to the Administrator and State Agency. The DON and a nurse allegedly dismissed the need for care, citing the resident's terminal condition. Discrepancies in staff accounts and lack of documentation further highlighted the facility's failure to adhere to reporting protocols.
The facility restricted visitation hours to between 8:00 AM and 8:00 PM, affecting all 143 residents. Residents reported being unaware of their right to 24-hour visitation. The Administrator confirmed the restricted hours, and the Business Office Manager stated that announcements were made each night about the end of visiting hours. The facility lacked a formal visitor policy, and the admission packet incorrectly stated visitation hours, leading to a deficiency in ensuring residents' visitation rights.
The facility failed to maintain the kitchen's ventilation hood filters and dish machine in a sanitary manner, with grease buildup on the hood and inadequate sanitization temperatures in the dish machine. The dish machine's temperature log showed consistently low temperatures, and maintenance staff found forks blocking the sensor and a thick slime buildup inside.
The facility failed to maintain resident dignity and respect, as staff entered rooms without knocking and a nurse stood while feeding a resident. Additionally, a family member fed two residents without sanitizing hands between them, with no staff intervention. The residents involved had severe cognitive impairments and required assistance with eating.
A resident expressed dissatisfaction with their doctor, Dr. F, for attempting to examine them without gloves while under contact precautions. The resident, with intact cognition, explicitly stated they no longer wanted Dr. F as their physician. Despite this, Dr. F planned to see the resident again, assuming they might have calmed down. The DON confirmed that residents could change doctors at any time, and Dr. F should have informed the facility of the resident's decision.
A resident with intact cognition was moved three times within four days without proper notice or explanation, violating their rights. The facility attempted a room change at 2:00 AM without providing a reason, leading to the resident's refusal. The DON acknowledged the failure to inform the resident, and the facility's policy requiring written notice was not followed.
A facility failed to execute a DNR Advance Directive order for a resident admitted for rehabilitation. The resident, who was cognitively intact and had a history of diabetes, hypertension, and end-stage renal disease, expressed their choice of DNR status during a health care conference. Although the DNR form was completed by the resident, it was not signed by a physician until after the resident's discharge, resulting in the resident remaining a full code during their stay.
A resident with a history of diabetes, falls, and anxiety experienced a disorganized discharge process, leading to confusion and distress. The resident and their spouse received conflicting information about the discharge, with no care conference held to discuss the plan. The resignation of the social work director added to the confusion, resulting in the resident being petitioned to a hospital for psychiatric evaluation due to alleged self-harm behaviors.
A facility failed to implement a baseline care plan for a resident receiving tube feeding. The resident, admitted with stroke, major depressive disorder, and malnutrition, had a severely impaired cognition score. Despite these conditions, the baseline care plan lacked instructions for tube feeding, which was confirmed by the DON.
The facility failed to ensure accurate medication documentation and complete tube feed orders for two residents. An LPN marked medications as given before a resident refused them, contrary to protocol. Another resident's tube feed orders lacked necessary details, confirmed by the RD and RN, indicating incomplete documentation.
The facility failed to provide appropriate wound care for two residents, resulting in untreated wounds and miscommunication about treatment completion. Additionally, the facility did not follow up on a physician consult for a resident with gangrene, lacking documentation of an after-visit summary. The Director of Nursing acknowledged the failures in both wound care and coordination of care for outside appointments.
A resident admitted with pressure ulcers did not have wound care orders placed, leading to inadequate care. The resident expressed pain and concern over unchanged dressings, and was found with an abdominal wound and stage two pressure sores. The wound care nurse confirmed that orders should have been in place, but were not, due to a lapse in the admission process.
A resident with a history of falls was not promptly assessed after a fall, despite reporting leg pain and hitting their head. The facility failed to communicate the incident to the resident's spouse, who was present at the facility. The resident's symptoms of pain and nausea were not addressed until the following day, highlighting deficiencies in post-fall assessment and communication.
A LTC facility failed to maintain proper infection control protocols, including hand hygiene during meals and PPE use for residents under contact precautions. A family member assisted two residents without hand hygiene, and a doctor did not wear gloves while examining a resident with a PICC line. Additionally, a resident was incorrectly placed in a contact precaution room. The facility's policies require PPE use and proper resident placement to prevent infection transmission.
A resident requiring a mechanical Hoyer lift for transfers was manually transferred by two CNAs, leading to knee pain and a complaint from the resident's daughter. The facility's investigation revealed that the staff did not adhere to the prescribed transfer method, resulting in a deficiency report.
The facility failed to maintain a clean, comfortable, safe, and homelike environment, with observations of soiled floors, walls, trash/debris, broken chair and tile, unsecured sharps and chemicals, and visible pests. Interviews with staff revealed inconsistencies in cleaning schedules and responsibilities.
The facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. A medication cart on the Oakridge Unit was observed unlocked and unattended, with medications accessible in all drawers, including the narcotic storage drawer. RN A confirmed the cart was left unlocked while a medication count was being performed away from the cart. The DON acknowledged that medication carts are to be locked and secured by authorized personnel.
Delayed Evaluation and Treatment of Foot Injury
Penalty
Summary
A resident with a history of orthostatic hypotension and syncope experienced a new onset of right foot pain after being assisted with a transfer. The pain was severe, with swelling and a high pain score reported. Nursing staff notified a nurse practitioner (NP) and a STAT X-ray was ordered, which initially showed no fracture. Despite ongoing complaints of pain, swelling, and the resident's inability to participate in physical and occupational therapy, there was no documented thorough evaluation of the right foot by a medical provider in the days following the injury. Progress notes indicated that the resident continued to experience significant pain and swelling, and therapy staff repeatedly documented the resident's inability to participate in therapy due to pain. Although the resident was seen by a PM&R physician and the NP was notified, documentation did not reflect a focused assessment of the injured area or address the acute pain and functional decline. The resident's pain was sometimes attributed to chronic neuropathy, and the acute injury was not specifically evaluated. It was not until six days after the initial injury that the attending physician documented a comprehensive assessment of the right ankle, noting significant swelling, bruising, and the resident's inability to bear weight. The resident was then placed on non-weightbearing status and referred for further evaluation. Subsequent imaging, including a CT scan, revealed a moderately comminuted avulsion fracture of the calcaneus with multiple displaced bony fragments. The delay in thorough evaluation and diagnosis resulted in prolonged pain and limited participation in rehabilitation. Interviews with facility staff, including the DON and PM&R physician, confirmed gaps in documentation and assessment, with uncertainty about which NP was contacted and a lack of clear documentation regarding the evaluation of the resident's acute injury.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bowel and bladder did not receive timely incontinence care. The resident reported being left wet and soiled for approximately 11 hours, from 4:00 AM to 3:00 PM, without being changed or repositioned. The resident stated that unless they used the call light, staff on the midnight shift did not check or reposition them, and if not changed during that shift, they had to wait until after breakfast. The resident described multiple unsuccessful attempts to have their brief changed, including using the call light several times and informing various staff members, but did not receive assistance until the evening shift began. Review of the clinical record showed the resident was dependent for toileting, had no bowel or bladder program, and was care planned for incontinence care per facility policy, with instructions to keep the resident clean and dry. Documentation for the day in question was incomplete, with no records of incontinence care provided during the day shift. The resident's complaints were corroborated by their email to the DON, which detailed the lack of response to call lights and the extended period without care, resulting in urine-soaked bed linens. Interviews with staff revealed confusion regarding room assignments, with the CNA assigned to the resident unaware of the assignment until the end of the shift. The DON confirmed that the standard of care was to check for incontinence every two hours, but there was no documentation of refusals or care provided on the day in question. The facility's policy required incontinence care as needed based on resident request or regular checks, but this was not followed, leading to the resident remaining soiled for an extended period.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications from a legally authorized representative for a resident diagnosed with Alzheimer's disease, fall from bed, and cerebral infarction. The resident, who had a BIMS score indicating moderately impaired cognition, was deemed incompetent to participate in medical decision-making due to dementia and visual hallucinations. Despite having a Durable Power of Attorney for Healthcare (DPOA-H) appointed, the facility administered psychotropic medications, including Sertraline and Lorazepam, without obtaining the necessary consent from the DPOA-H. The medical record review revealed multiple instances where Sertraline was prescribed and administered to the resident without documented consent from the DPOA-H. The facility's policy required informed consent for psychotropic medications, which was not adhered to in this case. The social worker acknowledged the lack of consent documentation and indicated that it was not brought to their attention that consent needed to be obtained. The facility's policy and procedures for psychotropic medication use were reviewed, highlighting the requirement for informed consent from the resident or authorized representative. Despite this policy, the facility did not provide documentation of consent from the DPOA-H for the psychotropic medications administered to the resident, including the multiple dose increases of Sertraline and the administration of Lorazepam.
Failure to Follow Pest Control Procedures Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to follow pest control procedures for a resident, leading to a bed bug infestation. The issue began when a resident's sister visited and brought in clothing and belongings from the resident's previous apartment, which were infested with bed bugs. The bed bugs were first noted on the resident in room 414L, and subsequently, the resident's roommate was also affected. The facility initiated its bed bug policy and procedures, which included showering the residents, moving them to new rooms, and cleaning their belongings. However, the procedures were not followed correctly, as evidenced by a CNA putting the same potentially infested clothes back on a resident after a shower, leading to bed bugs being found in the resident's hair the following day. The resident involved had a medical history including bipolar disorder and post-traumatic stress disorder, and required assistance with activities of daily living. The resident was upset about having to evacuate their room due to the bed bug infestation and experienced small bites on their inner thighs. The facility's failure to adhere to its pest control procedures resulted in the resident experiencing discomfort and requiring additional interventions to address the infestation. The CNA involved was unaware of the correct procedures and was subsequently disciplined and educated on the proper protocol.
Resident Abuse Due to Misplacement by Staff
Penalty
Summary
The facility failed to protect a resident, R803, from physical abuse by another resident, R804. The incident occurred when R804 pushed R803 out of their wheelchair, resulting in R803 falling. R803, who has Alzheimer's Disease with hallucinations and moderately impaired cognition, was mistakenly taken to R804's room by a dietary staff member. R804, who has severely impaired cognition, became irate upon finding R803 in his room and pushed him, leading to the fall. The incident was reported by a Licensed Practical Nurse (LPN) who heard screaming and found R803 on the floor near his wheelchair. R804 admitted to pushing R803, claiming that R803 was trying to take his belongings. The facility's investigation revealed that a dietary staff member, who was trying to be helpful, had assisted R803 into R804's room without knowing it was not R803's room. This led to the altercation between the two residents. The facility's policy on abuse, which states that residents have the right to be free from abuse, was not adhered to in this case. The lack of proper supervision and communication among staff members contributed to the incident. The dietary staff member involved was not aware of the residents' room assignments and did not consult with nursing staff before assisting R803, which ultimately led to the deficiency.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and the State Agency for a resident who was observed covered in dry feces. The incident was reported to a nurse and the Director of Nursing (DON) on the same day, but they allegedly indicated that incontinence care was not necessary as the resident was dying. The resident, who was cognitively intact, had been admitted with diagnoses including spontaneous bacterial peritonitis, cirrhosis of the liver, and malnutrition, and was discharged to home hospice care the following day. Interviews conducted during the investigation revealed discrepancies in staff accounts. The Unit Manager (UM) D, who was a family member of the resident, was not informed of the incident until after the resident's discharge. Nurse F, who was reportedly informed of the situation, denied any knowledge of the resident or the incident. The DON acknowledged hearing about the resident being left soiled but did not recall specific details or who reported it. The DON also mentioned that the resident had refused care and was combative, but no documentation supported this claim. The facility's policy requires immediate reporting of abuse or neglect allegations to the Administrator and the State Agency, but this protocol was not followed. The Administrator was unaware of the incident until informed by the DON days later. The DON later presented an undated investigation report, which included interviews with staff, but inconsistencies were noted, such as Nurse F's denial of involvement. The facility's failure to document and report the incident in a timely manner constitutes a deficiency in adhering to their abuse and neglect policies.
Facility Fails to Ensure 24-Hour Visitation Rights
Penalty
Summary
The facility failed to ensure unrestricted, 24-hour visitation rights for its residents, affecting all 143 residents. During a resident council meeting with the State Agency, several anonymous residents reported that the facility's visitor hours were restricted to between 8:00 AM and 8:00 PM, with the front door being locked at 8:00 PM. This was confirmed by the Administrator, who stated that the facility's visitor hours were indeed from 8:00 AM to 8:00 PM, and that this was announced overhead each night. The Administrator was unable to confirm whether residents were aware of their right to have visitors outside of these hours. Further investigation revealed that the facility did not have a formal visitor policy, and the admission packet provided to residents stated in large bold print that visitation was from 10:00 AM to 7:45 PM daily, with the lobby door locking at 8:00 PM. The Business Office Manager confirmed that announcements were made each night starting at 7:45 PM, informing residents and visitors of the end of visiting hours. This practice of restricting visitation hours and locking the front door at 8:00 PM was not in compliance with the residents' right to receive visitors of their choosing at any time.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain the kitchen's ventilation hood filters and dish machine in a sanitary manner, which could potentially affect all residents consuming food from the kitchen. During an observation, the cookline hood ventilation filters were found with a buildup of grease, and the Certified Dietary Manager (CDM) stated that kitchen staff were responsible for cleaning the hood vent. According to the 2017 FDA Food Code, non-food contact surfaces of equipment should be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the dish machine was not sanitizing properly. A plate simulating dishwasher tester recorded maximum temperatures of 152 and 153 degrees Fahrenheit, which were below the required 160 degrees Fahrenheit for sanitization. The dish machine's digital temperature display also showed inadequate rinse temperatures. The Temperature Log for the dish machine revealed consistently low temperatures, and the CDM was unaware of these issues. Maintenance staff later found forks blocking the sensor and a thick slime buildup inside the dish machine, further indicating a lack of proper maintenance and cleaning.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect, as evidenced by multiple observations of staff entering residents' rooms without knocking or announcing themselves. This was particularly noted in a secured unit where staff did not wait for acknowledgment before entering. Additionally, during a lunch meal, a nurse was observed standing while feeding a resident, despite available seating, which did not promote a dignified dining experience. Further dignity concerns arose when a family member was observed feeding two residents simultaneously without sanitizing their hands between assisting each resident. This occurred in the presence of nursing staff who did not intervene. The residents involved had severe cognitive impairments and required assistance with eating, as outlined in their care plans. The facility's policy on dignity, which mandates respectful treatment and acknowledgment before entering rooms, was not adhered to, leading to these deficiencies.
Failure to Honor Resident's Choice of Physician
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who expressed dissatisfaction with their current doctor, Dr. F. The resident, who was under contact precautions, reported that Dr. F attempted to examine their PICC line and foot wound without wearing gloves, which led to a confrontation. The resident, who had intact cognition as indicated by a BIMS score of 14/15, explicitly told Dr. F that they no longer wanted them as their doctor. Despite the resident's clear communication of their desire to change doctors, Dr. F intended to see the resident again, assuming the resident might have calmed down. The Director of Nursing confirmed that residents could change doctors at any time and acknowledged that Dr. F should have informed the facility of the resident's decision to terminate their services. The facility's admission contract supports the resident's right to choose their attending physician, yet this right was not initially honored in this instance.
Failure to Provide Proper Notice for Room Change
Penalty
Summary
The facility failed to provide appropriate notice in a dignified manner regarding a room change for a resident, identified as R289, who was reviewed for room changes. R289, who had been admitted with diagnoses including an open wound of the abdominal wall, prostate cancer, and chronic kidney disease, was observed in a different room than initially assigned. Over the course of four days, R289 was moved three times without proper notification or explanation. On one occasion, staff attempted to move R289 at 2:00 AM without providing a reason, leading to the resident's refusal to move. The resident, who had intact cognition as indicated by a BIMS score of 13/15, expressed awareness of their rights and questioned the staff's actions. The Director of Nursing (DON) acknowledged that R289 should have been informed of the reason for the room change, especially during the early morning hours. An LPN involved in the attempted room change at 2:00 AM stated that they informed R289 of the reason but could not provide specific details, which led to the resident threatening to contact their attorney. The facility's policy on room changes requires that residents receive written notice, including the reason for the change, and that discussions occur with the resident or their representative. This policy was not followed, resulting in a deficiency in honoring the resident's rights.
Failure to Implement DNR Order for Resident
Penalty
Summary
The facility failed to execute a Do-Not-Resuscitate (DNR) Advance Directive order for a resident who was admitted for rehabilitation from right toe gangrene. The resident had a medical history of diabetes, hypertension, end-stage renal disease, and required peritoneal dialysis. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 14/15. During a health care conference, the resident expressed their choice of DNR code status, and the DNR form was completed by the resident but was awaiting a physician's signature and order. Despite the resident's expressed wishes and the completion of the DNR form, the facility did not implement the DNR code status, and the resident remained a full code throughout their stay. The physician did not sign the DNR form until after the resident was discharged from the facility, as confirmed by the Corporate Social Services representative.
Disorganized Discharge Process Leads to Resident Confusion
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge process for a resident, leading to confusion and distress for both the resident and their spouse. The resident, who had a history of type two diabetes, repeated falls, and generalized anxiety disorder, was initially informed of their discharge on a specific date. However, due to a fall that occurred on the morning of the planned discharge, the discharge was postponed without clear communication to the resident and their spouse. The resident expressed dissatisfaction with the lack of organization and communication, stating that they had not been involved in a care conference to discuss their discharge plan. The situation was further complicated by the resignation of the social work director, leaving the new social worker uncertain about the discharge process. The resident and their spouse were given conflicting information about the discharge, leading to frustration and confusion. At one point, the resident attempted to leave the facility, believing they had been discharged, only to be told by the DON that necessary arrangements, such as home care and follow-up appointments, had not been made. The facility's lack of coordination and communication resulted in the resident being petitioned to a hospital for psychiatric evaluation due to alleged self-harm behaviors, although the resident insisted they were competent and not receiving adequate collaboration from the facility staff.
Failure to Implement Baseline Care Plan for Tube Feeding
Penalty
Summary
The facility failed to implement a baseline care plan for a resident who was receiving tube feeding. The resident, identified as R287, was admitted with diagnoses including stroke, major depressive disorder, and malnutrition, and had a severely impaired cognition score of 3/15 on the Brief Interview for Mental Status exam. Despite these conditions, the baseline care plan for R287 did not include instructions for tube feeding, which is necessary to meet the resident's immediate health and safety needs. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan for tube feeding should have been in place from admission.
Medication and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were accurately documented and orders were written according to professional standards of practice for two residents. For one resident, an LPN prepared seven medications, crushed them, and mixed them with applesauce. The resident refused to take the medications, but the LPN marked them as given before the refusal occurred. The LPN admitted to marking the medications as administered before the resident had taken them, which is against the facility's protocol. The Director of Nursing confirmed that medications should only be marked as given after the resident has taken them. For another resident, who was admitted with diagnoses including stroke, major depressive disorder, and malnutrition, there was a failure to document complete tube feed orders. The resident was receiving Jevity 1.5 Cal enteral nutrition at a specified rate, but the physician orders lacked details on the type of formula and infusion rate. The Registered Dietician and a Registered Nurse confirmed that the orders should have been complete with all required elements, and that a progress note was not sufficient for tube feed orders. The facility's job description for the Unit Charge Nurse indicates responsibility for ensuring complete and accurate nursing services, which was not met in this case.
Failure to Provide Wound Care and Follow-Up on Physician Consult
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, R337 and R120, as observed during the survey. R337, who was admitted with a surgical wound to the gallbladder, reported that their wound dressings had not been changed, resulting in a wound with blood and drainage that emitted a mild odor. The wound care nurse confirmed that there were no current orders for wound care, which should have been in place following the hospital paperwork. Similarly, R120, who had a wound vac and a hand dressing, reported that their hand dressing had not been changed since 7/31/24, despite the medication administration record indicating it was completed on 8/2/24. The wound care nurse and the Director of Nursing acknowledged a miscommunication regarding the completion of the treatment. Additionally, the facility failed to follow up on a physician consult appointment for R128, who was admitted for rehabilitation from right toe gangrene and had a medical history of diabetes, hypertension, and end-stage renal disease. The Director of Nursing acknowledged that the process for coordinating care for outside appointments was not followed correctly, as there was no documentation of an after-visit summary following a doctor's appointment attended by R128's daughter. The facility's policy on coordination of care for outside appointments was requested but not provided by the end of the survey.
Failure to Initiate Wound Care Orders on Admission
Penalty
Summary
The facility failed to ensure that wound care orders were placed for a resident upon admission, leading to inadequate care for pressure ulcers. On observation, the resident was found lying in bed, expressing pain and concern that their wound dressings had not been changed. The resident showed an abdominal wound with blood, drainage, and a mild odor, indicating a lack of timely wound care. Additionally, during incontinence care, the resident's coccyx area was observed to have a reddened border and a greenish-yellow slough base, with two stage two pressure sores on the left gluteal cheek. A review of the medical records revealed that the resident was admitted with diagnoses including hyperlipidemia, type two diabetes, and a mild protein deficit, and had an intact cognition. However, there were no wound care orders placed on the day of admission. The wound care nurse confirmed that there should have been orders in place, and explained that admitting nurses are responsible for obtaining treatment orders from doctors until wound care rounds can be conducted. This oversight resulted in the resident not receiving the necessary wound care upon admission.
Failure to Promptly Assess and Communicate After Resident Fall
Penalty
Summary
The facility failed to promptly assess a resident, identified as R29, after a fall, which occurred on the morning of 8/5/24. R29, who has a history of repeated falls and was supposed to receive assistance when using the restroom, was found unassisted in the bathroom. After the fall, R29 reported hitting their head and experiencing leg pain. However, the initial assessment by the nursing staff did not document any pain, and the resident was not thoroughly evaluated for potential injuries, such as a head injury, despite the fall. The nurse practitioner ordered a bolus for hypotension and neurochecks, but there was no immediate follow-up on the resident's complaints of pain and nausea. The following day, R29 reported feeling sick, experiencing vomiting, and continued leg pain, which they had communicated to the facility staff. However, the Unit Manager stated that R29 had not complained of any symptoms the previous day. It was only after further inquiry by the surveyor that the Unit Manager agreed to contact the doctor for further evaluation, including ordering x-rays and medication for nausea. Additionally, R29's spouse was not informed of the fall by the facility, despite being present at the facility all day. This lack of communication and delayed response to the resident's symptoms highlights the deficiency in the facility's protocol for post-fall assessment and communication with family members.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, particularly in hand hygiene during meals and the use of personal protective equipment (PPE) for residents under transmission-based precautions. During a dining observation, a family member was seen assisting two residents, R42 and R73, with their meals without using hand sanitizer or washing hands between assisting the residents. Despite the presence of nursing staff, no intervention was made to address the family member's actions. Both residents had severe cognitive impairments and required assistance with eating, as noted in their care plans. In another incident, R288, who was under contact precautions, reported that their doctor, Dr. F, touched their PICC line and foot wound dressing without wearing gloves. Despite being informed by R288 to wear gloves, Dr. F did not comply and expressed reluctance. The facility's infection control nurse and the director of nursing confirmed that all staff, including physicians, must wear PPE when entering a contact precaution room. R288 had intact cognition and refused further examination by Dr. F due to the lack of PPE use. Additionally, R289 was mistakenly placed in a contact precaution room, which was not appropriate given their medical condition. The resident was moved to a room with a contact precaution sign, but the midnight manager claimed there was no sign on the door at the time of the move. The director of nursing acknowledged the error and stated that R289 should not have been placed in that room. The facility's policy on infection control and transmission-based precautions emphasizes the importance of proper resident placement and the use of PPE to prevent the transmission of infectious agents.
Improper Transfer Method Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R901, according to the plan of care and facility policy. The resident, who required a mechanical Hoyer lift with two-person assistance for transfers, was instead transferred manually by two CNAs. During this transfer, the resident complained of knee pain, which was not immediately addressed by the staff. The incident was reported by the resident's daughter, who was present at the time and insisted on hospital evaluation for her mother. The investigation into the incident revealed discrepancies in the staff's account of the transfer. The CNAs involved in the transfer reported that the resident was assisted to stand and pivot without any signs of pain during the process. However, shortly after the transfer, the resident began to complain of knee pain, which led to further evaluation. The resident's daughter, although not witnessing the transfer, believed her mother's account of the incident, which included allegations of being dropped to the floor, although this was not corroborated by staff interviews. The facility's documentation and interviews with staff and the resident's daughter indicated a lack of adherence to the prescribed transfer method using a mechanical lift. The resident's care plan clearly stated the need for a mechanical lift, yet the staff opted for a manual transfer, which was against the facility's policy. This deviation from the care plan and policy led to the resident experiencing pain and the subsequent complaint filed with the State Agency.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by soiled floors, walls, trash/debris throughout the facility, broken chair and tile, unsecured sharps and chemicals, and visible harborage of pests. Multiple observations were made during the survey, including debris in hallways, soiled linens and used gloves on the floor, and unsecured chemicals in shower rooms. Additionally, there were instances of mold-like substances in grout, dead bugs in shower rooms, and food debris in dining areas. At various times during the survey, specific areas such as the Anna's House unit, Oakridge unit, and Hickory unit were found to have significant cleanliness issues. For example, the shower rooms had used briefs, gloves, towels, and washcloths scattered on the floor and handrails. Unsecured chemicals and personal care items were also found in these areas. The dining rooms had food debris, spider webs, and pests, and the flooring throughout the facility was littered with trash and debris. Interviews with staff, including the Director of Housekeeping and Laundry, revealed inconsistencies in cleaning schedules and responsibilities. Housekeeping staff were reported to clean certain areas before leaving for the day, but there were gaps in coverage, especially after dinner and on weekends. The Director of Housekeeping confirmed the observations and acknowledged the need for changes in cleaning routines and responsibilities. However, there was no clear policy or documentation provided by the facility to address the maintenance of a clean, comfortable, safe, and homelike environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. On 5/28/24 at 3:23 PM, a medication cart located on the Oakridge Unit, in front of room [ROOM NUMBER], was observed unlocked and unattended by authorized staff. The medications were accessible in all drawers, including the narcotic storage drawer. Registered Nurse (RN) A returned to the cart on the Oakridge Unit indicating a medication count was being performed with another nurse, away from the assigned medication cart. RN A confirmed the cart was left unlocked, unattended, and medications, including scheduled narcotics were accessible to unauthorized personnel. On 5/28/24 at 3:38 PM, the Director of Nursing (DON) was interviewed and acknowledged medication carts are to be locked and secured by authorized personnel. Review of the facilities policy titled 'Medication and Treatment Cart Storage' dated 5/4/22 documented that all drugs and biologicals will be stored in locked compartments (i.e., medication carts) and narcotics and controlled substances are to be stored under double-lock and key.
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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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