Four Seasons Nursing Center Of Westland
Inspection history, citations, penalties and survey trends for this long-term care facility in Westland, Michigan.
- Location
- 8365 Newburgh Road, Westland, Michigan 48185
- CMS Provider Number
- 235578
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Four Seasons Nursing Center Of Westland during CMS and state inspections, most recent first.
An LPN used a personal cell phone to record video from the facility’s camera system as part of a fall investigation and the footage, showing multiple cognitively impaired residents with clearly visible faces in a common day room, was later posted as a social media story. A resident with Alzheimer’s disease, a resident with schizophrenia, and two residents with dementia were identifiable in the images. The DON reported believing the video would be encrypted and deleted, but the facility’s social media and electronic communications policy strictly prohibited transmitting or posting any resident-related images or information that could violate privacy or confidentiality.
A medication administration error occurred when an LPN entered a resident’s room and, finding the resident’s sister lying in the bed while the resident was away, left the resident’s scheduled medications with the sister after she stated she would ensure the resident took them. The sister subsequently ingested the medications, experienced dizziness, and called 911, resulting in transport to the hospital. The medications, which included Metformin, Tamsulosin, Lactulose, spironolactone, and liquid protein, were documented on the MAR as having been given to the resident. The DON later stated the nurse should have followed the rights of medication administration and remained with the resident until medication administration was complete.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with muscle weakness and impaired cognition, who required staff assistance, did not have compression stockings applied as ordered by the physician to address leg swelling. Despite documentation indicating the stockings were applied, multiple observations confirmed they were not in place, and both the LPN and DON acknowledged the deficiency.
A resident admitted with intact skin and requiring staff assistance for mobility developed an unstageable pressure ulcer on the buttocks due to lack of regular turning, repositioning, and delayed incontinence care. Staff interviews indicated that standard interventions were in place for at-risk patients, but the wound still developed. Facility policy did not address prevention of wound development.
A resident admitted for hospice respite care did not have proper documentation for the administration and accountability of controlled substances, including morphine and lorazepam. Medication Administration Records were left blank despite controlled substance logs showing medication removals, with some entries later marked as errors and lacking clear staff identification. Facility staff could not explain the discrepancies or provide supporting documentation, and the required policy for documenting both removal and administration was not followed.
An unlocked medication cart was found unattended with an open monitor displaying personal information and an insulin pen stored on top. Multiple medicine cups containing pills, including some that should have been wasted, were discovered in the cart. A nurse confirmed the improper handling and storage of these medications, and the DON acknowledged these actions were not in accordance with facility policy.
A resident with functional quadriplegia and anxiety, dependent on staff for all ADLs, was found with excessively long and dirty fingernails. The resident wanted their nails trimmed but was anxious about the process. Nursing staff confirmed that regular nail care should be provided as part of ADLs, but this care was not given.
A resident requiring substantial assistance for ADLs and mobility experienced a prolonged delay of 33 minutes after activating their call light, during which staff failed to address their needs in a timely manner. Despite facility expectations for call lights to be answered within 10-20 minutes and for staff to address resident needs upon response, the resident remained wet and anxious until assistance was finally provided.
The facility failed to provide pureed food of the proper consistency, as observed with the pureed carrots served during lunch. The carrots contained small chunks requiring chewing, contrary to the IDDSI standards for a smooth, pudding-like texture. Both the dietician and chef confirmed the inconsistency.
The facility failed to reposition four dependent residents as required, leading to a deficiency in care. A resident with severe cognitive impairment was left in the same position for hours, despite needing assistance for mobility. Another resident with Parkinson's and stroke was not repositioned frequently, as their care plan required. Two other residents, one with a pressure ulcer, were also not repositioned as needed, despite facility policy mandating repositioning every two hours.
A resident with a brain tumor and dysphagia was incorrectly administered Jevity 1.5 instead of the prescribed Nutren 2.0 due to conflicting active orders. The dietician's order for Nutren was more recent, but both formulas were marked as given in the MAR. The DON confirmed that only one order should be active, highlighting a failure to follow the facility's policy on verifying physician orders.
The facility exceeded the acceptable medication error rate with a 6.25% error rate. A resident did not receive Lanthanum Carbonate due to unavailability, and two residents received incorrect Sennasides medication. The errors were observed and involved miscommunication and failure to adhere to medication administration policies.
The facility failed to properly label and date medications in two medication carts and two medication rooms. An Arnuity inhaler and lispro insulin were found without resident identifiers or opening dates. Tuberculin vials in two storage rooms were also not dated when opened, contrary to manufacturer instructions. The DON confirmed the requirement for dating tuberculin vials upon opening.
The facility failed to maintain infection control practices by allowing used urinals to remain on overbed tables for three residents. Observations showed urinals filled with urine on overbed tables, despite the facility's policy against such practices. The residents involved had various medical conditions and cognitive statuses. An interview with the Infection Control Nurse confirmed the breach of protocol.
The facility failed to ensure call lights were within reach for two dependent residents, leading to a deficiency. One resident, affected by a stroke, was unable to reach the call light due to limited mobility, while another resident with severe cognitive impairment had the call light out of reach. Both staff and facility policy confirmed the requirement for call lights to be accessible.
A resident with multiple health issues experienced a significant change in condition that was not addressed in a timely manner by the LTC facility staff. Despite family concerns and noticeable symptoms, the resident's deteriorating condition was not documented or communicated to the physician promptly. This led to the resident being transferred to the hospital in critical condition with severe complications, including a blood sugar level of 1200 mg/dl and respiratory distress.
A resident on anticoagulant medication sustained a fall with head trauma and bleeding, but the facility failed to conduct a comprehensive nursing assessment or ensure a timely hospital transfer. The initial response involved only applying a cold compress, and there was a lack of documentation and follow-up with the physician. It took over five hours for the unit manager to contact the medical director, who then ordered the resident's transfer to the hospital for treatment.
Two residents were involved in an incident where one poured water on the other after repeated requests for a room change were ignored. The resident who poured the water expressed frustration over the lack of response to their complaints about their roommate's disruptive behavior. Both residents have intact cognition and require assistance with mobility. The facility's failure to address the situation led to the abusive incident, contrary to its policy on preventing abuse.
A resident with dysphagia and multiple sclerosis did not receive a divided plate as per their nutritional care plan, leading to difficulty in self-feeding. The oversight was acknowledged by facility staff, including a CNA and the Dietary Manager, who confirmed the error occurred in the kitchen.
A resident with multiple sclerosis and intact cognition reported inadequate colostomy care, leading to the colostomy filling and bursting. The facility's Treatment Administration Record showed multiple instances of undocumented care, which the DON acknowledged and was working to address.
A resident admitted for short-term rehab fell and sustained injuries when a CNA failed to use a gait belt during a transfer, instead holding the resident's pants. The facility's policy mandates the use of gait belts for manual transfers, which was not followed, resulting in the resident's fall and injuries.
Unauthorized Social Media Posting of Resident Images by LPN
Penalty
Summary
The facility failed to protect residents’ privacy and right to confidentiality when an LPN used a personal cell phone to record video footage of a resident fall from the facility’s camera system and that video was subsequently posted to a social media account. The LPN reported that she recorded the fall as part of the facility’s fall investigation process using her personal phone and believed she had deleted the video before leaving the facility. However, a former facility employee later notified her that the video had been posted as a social media “story” clip. Photo stills taken from the LPN’s social media account showed residents sitting in a common day room area of the facility with their faces clearly visible. Four residents were identified as having their images and identities exposed in the social media post. One resident had been admitted with Alzheimer’s disease and was documented as severely cognitively impaired. A second resident had schizophrenia with a moderate cognitive impairment, and the third and fourth residents had dementia, with one having moderate and the other severe cognitive impairment. The DON stated that the LPN took a video of the camera system using her cell phone to better understand the resident’s fall and believed the video would be encrypted and deleted prior to her leaving the facility. The facility’s Social Media and Electronic Communications policy explicitly prohibited employees from transmitting any resident-related images or information via electronic media that could violate resident confidentiality or privacy, including posting or sharing any information regarding a resident, and this policy was not followed in this incident.
Improper Medication Administration to Visitor Instead of Resident
Penalty
Summary
A medication administration deficiency occurred when an LPN failed to properly identify and administer medications to the correct individual and did not remain with the resident until medications were taken. The resident involved had been admitted with diagnoses including diabetes, other cirrhosis of the liver, and heart failure, was cognitively intact, and required assistance with activities of daily living. On the morning in question, the resident’s sister was lying in the resident’s bed while the resident was not in the room. The LPN entered to administer the resident’s scheduled morning medications, which included Metformin, Tamsulosin (Flomax), Lactulose, spironolactone, and house liquid protein, and left the medications with the sister after she stated she would ensure the resident took them upon returning. Shortly thereafter, the sister independently contacted 911 and was transported to the hospital after consuming the medications that had been left in the room. The resident later reported that upon returning from the dining room, the sister informed them she had taken the medications and was feeling dizzy, leading her to call 911. The facility’s documentation and the February MAR showed that the medications were documented as administered to the resident at the scheduled time. The DON stated that the nurse should have followed the facility’s medication administration policy, including the rights of medication administration and remaining with the resident until medication administration was complete.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect residents from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
A deficiency occurred when staff failed to apply compression stockings as ordered by the physician for one resident. The resident, who had diagnoses of muscle weakness and disorder of muscle, was admitted with an order to have compression stockings applied to both lower extremities at 6:00 AM and removed at 10:00 PM daily. Despite this order, the resident was observed multiple times throughout the day without compression stockings in place, although the Medication Administration Record indicated they had been applied. The resident reported that the stockings had only been put on once or twice, and staff confirmed the absence of the stockings during interviews. The resident had impaired cognition, requiring staff assistance with bed mobility and transfers, and was noted to have swollen and painful legs. Observations confirmed the resident was only wearing heel boots and not the prescribed compression stockings. When questioned, the LPN acknowledged the resident did not have the stockings on and would attempt to locate them. The Director of Nursing was aware of the issue and stated that compression stockings were expected to be applied as ordered. The facility's policy on physician and practitioner orders did not address the need to follow physician orders.
Failure to Prevent Development of Unstageable Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with intact skin and medical diagnoses of muscle weakness and lymphedema. The resident required staff assistance for bed mobility and transfers and had an intact cognitive status. Upon admission, the skin evaluation showed no abnormalities. However, an open area was first observed on the resident's buttocks nearly a month after admission. Subsequent skin evaluation documented the wound as unstageable, with measurements indicating deterioration. The wound was attributed to the resident not being turned and repositioned as needed, as well as delays in incontinence care. Interviews with facility staff revealed that the wound care nurse was informed of the wound during routine rounds and immediately involved the wound care physician for assessment and intervention. The wound care nurse stated that turning and repositioning are standard interventions for at-risk patients but was unsure how the wound developed in this case. The Director of Nursing confirmed being notified of the wound after its discovery and that interventions were implemented at that time. Review of facility policy showed that the skin and wound guidelines did not address prevention of wound development.
Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for a resident admitted for a five-day hospice respite stay. The resident, who had multiple complex diagnoses including palliative care, multiple sclerosis, and seizures, had orders for controlled substances such as liquid morphine and lorazepam for pain and anxiety. Review of the Medication Administration Records (MARs) showed no documentation of administration for these medications, despite controlled substance proof of use records indicating that doses were removed from inventory. Controlled substance records showed multiple entries for removal of lorazepam and morphine, with some entries initialed by a nurse and others with illegible or unidentifiable initials. Several entries for morphine were later marked as errors and corrected, but there was no documentation of medication being wasted or administered, and the MARs remained blank. Progress notes and vital signs did not indicate the resident experienced pain or anxiety that would correspond with the medication removals, and there was no explanation in the clinical record for the discrepancies. Interviews with facility staff, including the DON and unit manager, revealed they were unable to explain the discrepancies or identify all staff involved in the documentation. The facility's policy required nurses to document both the removal and administration of controlled substances, but this was not followed. Attempts to contact the nurse responsible for the entries were unsuccessful, and staff acknowledged concerns with the documentation but could not provide further clarification.
Improper Medication Storage and Handling
Penalty
Summary
Surveyors observed an unlocked medication cart on the Spring Unit with no licensed staff present. The cart had an open monitor displaying personal information for a resident, and an insulin pen was stored on top of the cart. Upon opening the top drawer, several clear medicine cups containing pills were found, including one cup with five pills identified as medications for a specific resident. Two other cups contained single white pills. A registered nurse later confirmed the medications and explained that the other two cups were intended to be wasted, one because the pill had fallen on the floor and the other because the medication was no longer ordered for the resident. The nurse did not provide a reason for not immediately wasting the medications or for removing a medication that was not part of the current order. The Director of Nursing confirmed that the observed practices did not align with facility policy, which requires all medications and biologicals to be stored in locked compartments and for medications to be under direct observation or locked during medication passes. The failure to lock the medication cart, improper storage of insulin, and the presence of unadministered and unaccounted-for medications in the cart constituted a breach of medication storage and handling protocols.
Failure to Provide Regular Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, functional quadriplegia, and anxiety, who required substantial staff assistance for all activities of daily living (ADLs) and mobility, was observed to have very long fingernails extending about 3/4 of an inch beyond the fingertips, with visible debris that was yellow and darker in color. The resident expressed a desire to have their nails trimmed but also reported anxiety about the process, fearing their skin might be nipped. Interviews with nursing staff, including an RN and the ADON, confirmed that regular nail care should be provided as part of ADLs, indicating that the facility failed to provide necessary nail care for this resident.
Delayed Call Light Response and Failure to Address Resident Needs
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, functional quadriplegia, and anxiety, who required substantial assistance for all activities of daily living and mobility, experienced significant delays in having their call light answered. The resident reported that after activating the call light, it often took a very long time for staff to respond, and expressed concern that frequent use of the call light was discouraged by staff. During observation, the resident activated the call light and waited 33 minutes before their needs were addressed. During this period, a registered nurse entered the room, was informed of the resident's needs, and stated they would notify the assigned CNA. Another CNA entered, turned off the call light, and left without addressing the resident's needs, stating the assigned CNA would be there soon. The resident remained wet and anxious until the assigned CNA arrived and provided assistance. Interviews with nursing staff revealed that the facility's expectation for answering call lights is within 10 to 20 minutes, and that the person responding to the call light is expected to address the resident's needs directly, rather than turning off the light and leaving. The observed delay and failure to address the resident's needs upon initial response did not meet these expectations, resulting in the resident remaining in discomfort and distress for an extended period.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were of the proper consistency, specifically affecting the pureed carrots served during lunch. During an observation of the lunch tray-line service in the main kitchen, a pan of pureed carrots was noted to contain small chunks of orange carrot bits mixed with a pale orange viscous substance. A taste test confirmed that the pureed carrots contained small chunks that required chewing before swallowing, which is inconsistent with the requirements for a pureed diet. According to the IDDSI chart posted in the facility kitchen, pureed foods should be smooth and have a pudding-like texture with no lumps. Both the dietician and the chef acknowledged that the pureed carrots did not meet the proper consistency standards for a pureed diet.
Failure to Reposition Dependent Residents
Penalty
Summary
The facility failed to provide timely repositioning for four dependent residents, leading to a deficiency in care. Resident #34 was observed multiple times over several days to be in the same position for extended periods, despite a care plan that required repositioning every two hours. The resident had severe cognitive impairment and required substantial assistance for mobility, yet was left in the same position for hours, indicating a lack of adherence to the care plan. Resident #44, who had diagnoses including Parkinson's and stroke, was also observed to remain on their backside in bed for extended periods without repositioning, despite requiring frequent turning and repositioning as per their care plan. The resident's condition necessitated a two-person assist for bed mobility, yet observations showed a lack of repositioning, which could contribute to further health complications. Similarly, Resident #97 and Resident #118 were observed in positions that did not change over several hours, with no visible positioning devices used to aid in repositioning. Both residents had severe cognitive impairments and were dependent on staff for mobility. Resident #118 had a documented pressure ulcer, yet was not repositioned as required, which could exacerbate their condition. The facility's policy required repositioning every two hours, but this standard was not met, as confirmed by the Director of Nursing.
Incorrect Tube Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct tube feeding formula to a resident, identified as R119, who was observed to have been receiving Jevity 1.5 instead of the prescribed Nutren 2.0. This discrepancy was noted during observations on consecutive days, where bottles of Jevity 1.5 were found in the resident's room and trash can. A review of R119's medical records revealed conflicting active orders for both Jevity and Nutren, with the Nutren order being the more recent and prescribed by the dietician. Despite this, both formulas were marked as administered in the resident's Medication Administration Record (MAR) for several days. R119, who has a diagnosis of a benign brain tumor and dysphagia, was admitted with specific nutritional needs that required precise tube feeding management. The Registered Dietician confirmed that the Nutren 2.0 order was based on the resident's nutritional requirements, while the Jevity order was incorrectly entered by a nurse. The Director of Nursing acknowledged that only one tube feeding order should be active, as per the facility's policy, which mandates verification of physician orders prior to administration. This oversight in following the correct tube feeding order led to the administration of an incorrect formula to the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. During a medication pass observation, a Registered Nurse (RN) was unable to administer Lanthanum Carbonate, 1000 mg, to a resident because it was not available. Instead, the RN attempted to substitute it with two calcium carbonate 500 mg tablets, but the order was not reviewed properly, and the Lanthanum Carbonate was not given. The medication administration records indicated that the medication was documented as given 19 times, despite not being available. Communication from the Director of Nursing revealed that the medication order should have been discontinued based on lab results and nephrology recommendations, indicating a lack of coordination and communication regarding the resident's medication needs. Additionally, two separate incidents involved the incorrect dispensing of Sennasides. An RN and an LPN both dispensed Sennasides 8.6 mg pills from over-the-counter stock instead of the ordered Sennasides with Docusate Sodium 8.6 mg/50 mg pills for two different residents. These errors were observed and later reviewed with the Director of Nursing. The facility's policies on medication administration and error definitions were not adhered to, as evidenced by the wrong medication being dispensed and the omission of a prescribed drug.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and dating of medications in two of five medication carts and two medication rooms. During an inspection, it was observed that an Arnuity inhaler on the Spring unit front cart was not labeled with a resident identifier and lacked a date of opening on both the inhaler and its box. Similarly, a lispro insulin on the Spring unit back cart was found without a date of opening and resident identifier. In the Winter medication storage room, a tuberculin derivative vial was not dated when opened, and the same issue was noted in the Summer medication storage room. The Director of Nursing confirmed that tuberculin vials should be dated upon opening. Manufacturer instructions for the tuberculin vial indicated that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. Additionally, the prescribing information for the Arnuity Inhaler specified that it should be discarded 6 weeks after opening or when the counter reads 0, whichever comes first.
Infection Control Lapse with Urinals on Overbed Tables
Penalty
Summary
The facility failed to maintain proper infection control practices by allowing used urinals to remain on overbed tables for three residents. During observations, it was noted that one resident had a urinal half-filled with urine on the overbed table while preparing for breakfast. Another resident had a urinal quarter-filled with urine on the overbed table after having breakfast, and a third resident was observed with a urinal filled with urine on the overbed table. These observations were made during a specific time frame, indicating a lapse in infection control protocols. The medical records of the residents involved revealed various diagnoses, including atherosclerotic heart disease, muscle weakness, atrial fibrillation, cervical disc disorder, anemia, fracture of the lower end of the right ulna, disorder of the muscle, and osteoarthritis. The cognitive assessments of the residents varied, with one resident being cognitively intact and the others having moderate cognitive impairment. An interview with the Infection Control Nurse confirmed that urinals should not be stored on overbed tables, aligning with the facility's infection control policy, which emphasizes standard precautions to prevent the spread of infection.
Deficiency in Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two dependent residents, leading to a deficiency in resident care. Resident 42, who had limited mobility due to a stroke, was observed in a recliner and later in bed with the call light tucked under the pillow, out of reach. Despite attempts to reach the call light with their right hand, Resident 42 was unable to do so due to the inability to move their left arm. The care plan for Resident 42, which noted an alteration in mobility and a self-care deficit, did not include an intervention for call light placement. Resident 24, diagnosed with unspecified dementia and having a severe cognitive impairment, was repeatedly observed in bed with the call light hanging on the wall behind the bed, out of reach. When asked, Resident 24 confirmed they could not reach the call light and did not know what to do if they needed help. Both a Licensed Practical Nurse and the Director of Nursing confirmed that call lights should always be within reach of residents. The facility's policy on call light accessibility and timely response mandates that call lights be plugged in, functioning, and within reach of residents.
Failure to Address Change in Condition Leads to Resident Hospitalization
Penalty
Summary
The facility failed to address a significant change in condition for a resident, leading to a critical health emergency. The resident, who had a history of acute kidney failure, type 2 diabetes mellitus, dysphagia, dementia, seizures, hypertension, and aphasia, was found to have a blood sugar level of 1200 mg/dl, fever, and difficulty breathing, requiring mechanical ventilation upon transfer to the hospital. The resident's family had reported noticeable swelling and increased sleepiness as early as December 21, but these concerns were not adequately addressed by the facility staff. On January 3, the resident was found in respiratory distress with low oxygen saturation and was only responsive to painful stimuli. Despite these alarming signs, there was a delay in notifying the physician and transferring the resident to the hospital. The facility's staff, including LPNs and CNAs, failed to document the resident's deteriorating condition and did not follow the protocol for notifying the physician of significant changes in the resident's status. The physician was eventually contacted, and the resident was transferred to the hospital, but by then, the resident was in critical condition with sepsis and other severe complications. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. The unit manager and the Director of Nursing did not provide clear guidance or follow-up on the resident's change in condition. The facility's policy on change in condition notification was not adhered to, as the nurse did not document the resident's condition or notify the physician in a timely manner, contributing to the resident's critical health emergency.
Failure to Ensure Timely Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive nursing assessment and timely acute care emergent hospital transfer for a resident who sustained a fall with head trauma and bleeding while on anticoagulant medication. The incident occurred when the resident was found sitting on the floor with a head laceration after hitting the back of their head on the wall. Despite the resident experiencing significant pain and being on a blood thinner, the initial response by the LPN involved only applying a cold compress and awaiting a call back from the physician, which was not documented as received. The resident's medical records revealed a lack of documentation regarding the extent of the wound, the amount of bleeding, and whether the bleeding had stopped. The resident's care plan indicated a risk for bleeding due to anticoagulant use, yet there was no immediate follow-up with the physician or an emergent transfer to the hospital. It was not until over five hours later that the unit manager contacted the medical director, who ordered the resident's transfer to the hospital, where the head wound was treated with staples. Interviews with facility staff highlighted a failure to follow protocol, as the LPN did not perform a comprehensive skin assessment or notify the medical director when the physician was unreachable. The unit manager and other LPNs expressed that the resident should have been sent to the hospital immediately after the fall, given the open head wound and the resident's anticoagulant medication. The facility's policies on fall management and physician services were not adhered to, resulting in a delayed response to the resident's acute condition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, R700 and R701. The incident occurred when R701 poured water on R700, reportedly after months of requesting a room change due to R700's behavior, which R701 found disruptive. R700, who has diagnoses of Functional Quadriplegia, Depression, and Anxiety, reported the incident, stating that R701 poured water on them repeatedly. R701, diagnosed with Schizophrenia and Muscle Weakness, admitted to the act, expressing frustration over the lack of response to their requests for a new roommate. Both residents have intact cognition, as indicated by their Brief Interview for Mental Status scores. The facility's failure to address R701's repeated requests for a room change contributed to the escalation of the situation, resulting in the abusive incident. Interviews revealed that R701 had informed numerous staff members about their desire for a new roommate due to R700's constant screaming, which affected R701's ability to sleep. The Nursing Home Administrator was unaware of R701's complaints about R700, indicating a communication breakdown within the facility. The facility's policy on abuse emphasizes residents' rights to be free from abuse, neglect, and mistreatment, which was not upheld in this case.
Failure to Implement Nutritional Care Plan Intervention
Penalty
Summary
The facility failed to implement a nutritional care plan intervention for a resident with dysphagia and multiple sclerosis. The resident, who had an intact cognition and required assistance with bed mobility and transfers, was observed eating lunch in their room. The resident expressed difficulty in eating and was seen using a regular plate instead of the prescribed divided plate, which was intended to assist with self-feeding. This discrepancy was noted by a Certified Nursing Assistant who confirmed that the resident should have been provided with a divided plate as per the diet ticket. Interviews with the Director of Nursing and the Dietary Manager revealed that the oversight occurred in the kitchen, resulting in the resident not receiving the appropriate plate. The facility's policy on care plan comprehensive and revision emphasizes the importance of selecting interventions based on thorough data gathering and clinical decision-making. However, in this instance, the intervention to provide a divided plate was not implemented, leading to the deficiency noted by the surveyors.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide and document adequate colostomy care for a resident, identified as R702, who was admitted with diagnoses of dysphagia and multiple sclerosis. The resident, who has intact cognition, reported that the facility staff did not empty their colostomy as frequently as required, leading to the colostomy filling, bursting, and necessitating frequent changes. This issue was corroborated by a review of the Treatment Administration Record (TAR) for September and October, which showed multiple instances where colostomy care was not documented during the AM shift. The Director of Nursing (DON) acknowledged receiving numerous complaints from the resident regarding the colostomy care, specifically about emptying and changing it. The DON mentioned that efforts were being made to address these complaints and improve documentation. The facility's policy on ostomy care requires documentation of the procedure in the resident's electronic health record, which was not consistently followed, as evidenced by the blank spaces in the TAR.
Failure to Use Gait Belt During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to implement measures to reduce the risk of a fall with injury for a resident admitted for short-term rehab following a trigger finger repair surgery. The resident, who required minimal assistance for transfers, reported falling while being assisted by a CNA. The CNA admitted to not using a gait belt during the transfer, instead holding the resident's pants, which led to the resident falling forward and sustaining injuries to the forehead, right forearm, and knees. The facility's policy mandates the use of gait belts during transfers, which was not followed in this instance. The incident was confirmed through a review of the facility's Incident/Accident reports and interviews with the resident and the CNA involved. The Director of Nursing also confirmed that the expectation is for gait belts to be used with any resident requiring manual transfer assistance. The failure to adhere to this policy resulted in the resident's fall and subsequent injuries, highlighting a lapse in following established safety protocols.
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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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