Grand Oaks Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwin, Michigan.
- Location
- 600 Denmark Street, Baldwin, Michigan 49304
- CMS Provider Number
- 235499
- Inspections on file
- 25
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Grand Oaks Nursing Center during CMS and state inspections, most recent first.
A resident with diabetes, CHF, CKD, a history of inguinal hernia, and a suprapubic catheter did not receive appropriate assessment, monitoring, documentation, and care planning for multiple active conditions. Hospital instructions and recommendations for hernia management, including use of a support device and strict return precautions, were not clearly documented or followed up, and there was no ongoing hernia assessment despite repeated reports of the hernia being "out" and subsequent hospitalization for small bowel obstruction and incarcerated hernia. The resident’s CKD, hyperkalemia, and hyponatremia were treated with medications such as Lokelma and sodium chloride without documented ongoing lab monitoring or evidence of stability, and CHF management lacked a specific care plan, baseline weight reference, or documented monitoring despite fluid restriction, diuretic, and midodrine orders. Skin assessments showed dry, reddened, and excoriated areas and boggy heels, but care plans did not include a pressure ulcer risk focus, wound interventions, or a pruritis care plan. There was also confusion and conflicting documentation between Foley and suprapubic catheter care, with the resident observed having a suprapubic catheter and excoriated skin at the site while the MAR and care plans contained Foley-focused orders and lacked clear suprapubic catheter interventions.
A cognitively impaired resident with Alzheimer’s disease, dementia, anxiety, and hallucinations was subjected to verbal and physical abuse by a podiatrist during a visit in her room. Staff in a nearby room heard thumping, scuffling, and a male voice yelling and swearing, including statements such as not to "f*ck*ng" lay hands on him. A CNA reported seeing the podiatrist push the resident, causing her to fall back onto her bed, while the resident yelled at him to get out. The DOR found the resident on her bed, glasses displaced, arms flailing, yelling, crying, and physically upset. A post‑incident assessment documented redness on the resident’s forearm, a complaint of wrist pain, and her statement that people had been "beating [her] with hammers." The podiatrist had been entering resident rooms alone to provide services, and his conduct toward this resident met the facility’s own definitions of verbal and physical abuse.
The facility failed to ensure call lights were within reach for two residents with dementia and mobility assistance needs. One resident's call light was repeatedly found out of reach, despite her ability to use it when accessible. Another resident's call light was coiled on the bed, out of reach, while she sat in a chair. Both residents' care plans required staff to keep call lights accessible, which was not consistently followed.
The facility failed to implement effective antibiotic stewardship, leading to inappropriate antibiotic use for two residents. A resident with frequent UTIs received multiple antibiotics, but records were incomplete and inaccurate. Another resident was discharged with antibiotics not tracked by the facility. The Infection Control Preventionist reported issues with the tracking system and lack of follow-up on antibiotics administered over weekends.
A resident's dignity was compromised when a CNA engaged in a verbal altercation with her, making disrespectful comments and failing to maintain a professional demeanor. The incident involved the CNA asking the resident why she was 'mean muggin'' him, leading to an argument where the CNA made further inappropriate remarks.
The facility failed to implement adequate care plans for two residents, leading to deficiencies in their care. One resident, with morbid obesity and dementia, developed pressure ulcers without a care plan focus on prevention or management. Another resident, with dementia and chronic kidney disease, experienced frequent incontinence episodes without sufficient care plan interventions to address his toileting needs.
A resident with CHF and Morbid Obesity experienced significant weight gain, but the facility failed to revise her care plan to include personalized interventions, despite her expressed desire to lose weight. The care plan had not been updated since July, and the interdisciplinary care conference did not involve the resident's input or address her specific needs.
A resident with a history of dementia, chronic kidney disease, and frequent UTIs did not receive appropriate continuity of care in an LTC facility. Despite multiple antibiotic treatments and a urology consultation, there was no follow-up on planned interventions or documentation of the root cause of the UTIs. The care plan lacked focus on urinary issues, and staff did not consistently document or assist with toileting needs, leading to a deficiency in quality of care.
A facility failed to provide adequate pressure ulcer care for a resident with morbid obesity, dementia, and mixed incontinence. The resident developed two Stage II pressure wounds, but treatment orders were delayed, and required dressings were missing. The care plan lacked focus on active pressure ulcers, and staff reported difficulties in repositioning the resident. The Director of Nursing confirmed inaccuracies in skin assessments and care plans, and the facility's policy on skin assessment and treatment was not followed.
A resident with morbid obesity, dementia, and mixed incontinence was not provided timely incontinence care, resulting in moisture-associated skin damage (MASD). The resident was found in a wet chair with saturated briefs, and the CNA did not apply barrier cream due to unavailability. The resident was toileted only 2-4 times daily, with long intervals between, contrary to the facility's policy of every two hours. The Care Plan lacked MASD interventions, and the Director of Nursing acknowledged the failure to meet care expectations.
The facility failed to notify a medical provider of significant weight changes for two residents. One resident experienced a notable weight loss, while another had weight increases over several months. Despite expectations for documentation and notification, there was no evidence that the medical provider was informed of these changes.
Two residents received incontinence care without proper hand hygiene, leading to a deficiency in infection control. One resident, with cognitive impairment and incontinence, was cared for by CNAs who failed to change gloves or sanitize hands after handling soiled items. Another resident, with a yeast infection, received peri care from CNAs who did not change gloves or sanitize hands after touching contaminated surfaces. The facility's LPN confirmed the requirement for hand hygiene but noted a lack of recent audits.
An LPN in a LTC facility administered all daily medications at once to several residents, leading to a resident's hospitalization and another experiencing hypoglycemia. The LPN admitted to the error, which was done for time management, and subsequently resigned.
A resident reported feeling intimidated and threatened by an LPN, who allegedly yelled and made threatening remarks. The facility failed to report these allegations to the state survey agency in a timely manner, and the initial report was incomplete. The DON and NHA were informed but did not document or investigate the allegations promptly.
A resident with dementia was involved in an altercation, but the incident was not properly documented in her medical records. The DON acknowledged the lack of detail in the documentation, which focused on the resident's agitation related to bowel movements rather than the altercation itself. This failure to maintain accurate records is critical for effective communication and care.
Failure to Assess, Monitor, and Care Plan for Complex Medical Conditions and Devices
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess, monitor, document, and care plan for a cognitively intact resident with multiple complex medical conditions, including diabetes, CHF, CKD, benign prostatic hyperplasia, a history of hernia with repair, and a suprapubic catheter. The resident was observed with disheveled hair and scabbing on his head, reporting that he scratched due to itching. A skin assessment documented red, dry bilateral lower extremities with scratch marks, boggy blanchable heels, and red, excoriated posterior thighs, yet the care plan only referenced a history of skin impairment and MASD to the right posterior thigh and did not include a specific pressure ulcer risk focus, wound interventions for the heel, suprapubic exit site excoriation, or MASD prevention. There was also no care plan for pruritis despite orders for topical treatments for itchy skin. Regarding the resident’s hernia and related pain, hospital emergency room notes documented a right inguinal hernia that was reduced with instructions for “strict return precautions,” but these precautions were not clarified or documented in the EMR. A nursing note relayed a hospital recommendation for an over-the-counter hernia support device and instructions to reduce the hernia if it returned, but there was no documentation that the resident ever received the hernia support or that ongoing hernia assessments and monitoring occurred. Subsequent nursing notes described episodes where the resident reported his hernia was “out,” received Norco, and was positioned with head down and feet up, but there was no ongoing assessment or monitoring documented. Later, the resident was sent to the ED with abdominal distention and brown emesis and was diagnosed with small bowel obstruction, right inguinal hernia, pneumatosis intestinalis, and AKI, with hospital records noting an incarcerated inguinal hernia and conservative management with a scrotal support belt; however, the care plan remained vague, not focused on the hernia, and contained no specific hernia-related interventions or updates after hospital return. The facility also failed to adequately monitor and care plan for the resident’s CKD, hyperkalemia, hyponatremia, and CHF. Labs showed elevated potassium and reduced eGFR consistent with CKD stage III, and the practitioner added Lokelma for hyperkalemia, but there were no subsequent potassium labs in the EMR to reflect ongoing monitoring or stability on this medication, despite continued Lokelma orders and the resident at one point declining the medication. Sodium chloride and Lokelma were ordered without documentation of ongoing sodium and potassium monitoring or evidence that the resident was stable on these medications. The resident had CHF with orders for Lasix, a fluid restriction, and midodrine (first scheduled, then PRN for MAP < 65), but there was no documented CHF monitoring protocol, no baseline reference weight clearly established, and no CHF-focused care plan or interventions, despite multiple weight fluctuations and the DON’s acknowledgment that staff likely did not know how to calculate MAP and that the order lacked typical nursing home parameters. In addition, the facility did not maintain accurate documentation or appropriate care planning for the resident’s suprapubic catheter. Staff interviews revealed confusion between a Foley catheter and a suprapubic catheter, with the EMR and MAR listing Foley catheter care orders while the resident actually had a suprapubic catheter. The resident was observed with a suprapubic catheter in place, no T-sponge, and surrounding skin that was red and excoriated, while the MAR contained both Foley catheter care orders and suprapubic catheter care orders, with the suprapubic site care order discontinued. The ADL care plan referenced Foley catheter care and a closed drainage system, but the elimination care plan described a suprapubic catheter in place for obstructive reflux uropathy and increased UTI risk, without specific suprapubic catheter interventions. Overall, the care plans contained incorrect or missing information about the resident’s current medical status and lacked pertinent interventions for the hernia, CKD, hyperkalemia, hyponatremia, CHF, suprapubic catheter, and skin conditions, and the facility did not ensure consistent assessment, monitoring, and documentation aligned with the resident’s needs and medical orders.
Failure to Protect Cognitively Impaired Resident From Verbal and Physical Abuse by Podiatrist
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from verbal and physical abuse by an ancillary service provider, specifically the podiatrist. The resident had Alzheimer’s disease, dementia, anxiety disorder, osteoarthritis, muscle weakness, unsteadiness on feet, and auditory and visual hallucinations, and was documented as severely cognitively impaired with a BIMS score of 01. She required one-person assistance with ADLs, ambulated with a 4‑wheeled walker, and her daughter was the DPOA and decision maker. On observation the day after the incident, the resident was fully dressed, sitting on the side of the bed with her walker in front of her, talking to herself, not engaging with the surveyor, and appeared calm and free from visible bruises. According to staff interviews, CNA A, the DOR, and PTA D were in a nearby room when they heard thumping, scuffling, loud noises, and a male voice yelling and swearing coming from the resident’s room. CNA A reported hearing the podiatrist say, “Don’t f*ck*ng hit me,” and then, upon entering the hallway, observed the resident about three feet from her bed moving toward the podiatrist. CNA A stated he saw the podiatrist push the resident, causing her to fall back onto her bed, and heard the resident yelling at him to get out. CNA A described the podiatrist attempting to leave the area and trying to get past him, while CNA A blocked his path and instructed him not to go by other residents. PTA D corroborated hearing aggression in the male voice, yelling, swearing, and the resident being upset. The DOR reported hearing a man swearing and clearly saying, “Do not F*ck*ng lay hands on me again,” followed by CNA A stating that the resident needed help and that he had witnessed abuse. When the DOR entered the resident’s room, she found the resident on her bed with glasses askew, arms flailing, yelling, crying, and physically upset. The DON’s documentation and interview indicated that staff had reported raised voices and that the podiatrist was observed yelling at the resident, with staff reporting that the resident was attempting to ambulate past him when he pushed her back onto the bed. A post‑incident assessment noted redness on the resident’s left forearm in a broad irregular shape and a complaint of right wrist pain, though she was able to move the wrist without observable signs of pain. During assessment, the resident was tearful, resistant to touch, and repeatedly hugged a stuffed dog, and she stated that people had been “beating [her] with hammers.” The DON also reported that the podiatrist stated the resident had assaulted him and that he had previously entered resident rooms alone to provide services. These events demonstrate that the resident was subjected to verbal and physical abuse by the podiatrist, contrary to the facility’s abuse policy defining abuse as willful infliction of injury, intimidation, or conduct causing or potentially causing humiliation, fear, or mental anguish.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently left within reach for two residents, both of whom were moderately cognitively impaired and required staff assistance for mobility. Resident 30, who was admitted with dementia and weakness, was observed multiple times with her call light out of reach, either hanging from the wall or under her pillow. Despite being able to use the call light when it was accessible, she frequently reported being unable to locate it. The care plan for Resident 30 directed staff to maintain personal items within her reach and encourage the use of the call light, but this was not consistently followed. Similarly, Resident 22, also admitted with dementia and weakness, was observed with her call light coiled up on her bed and out of reach while she sat in a bedside chair. She was dependent on staff for ambulation and was unaware of the call light's location. The care plan for Resident 22 included instructions to remind her to use the call light and ensure it was within reach, which was not adhered to. The Director of Nursing confirmed that both residents were capable of using their call lights and that staff should have left them within reach.
Inadequate Antibiotic Stewardship and Tracking
Penalty
Summary
The facility failed to adhere to its antimicrobial stewardship policy, resulting in inappropriate antibiotic use for two residents. The policy, last revised in March 2020, mandates the use of antimicrobial stewardship strategies to improve therapy quality, minimize resistance, and optimize outcomes. However, the facility did not have an effective system for assessing, monitoring, and preventing unnecessary antibiotic usage, as evidenced by the incomplete and incorrect tracking of antibiotics administered to residents. Resident #39, who has a history of frequent urinary tract infections (UTIs) and other medical conditions, was administered multiple antibiotics over several months. The facility's records did not accurately reflect all antibiotics given, such as ceftriaxone, amoxicillin, and ciprofloxacin, among others. The infection control records were incomplete, and the Infection Control Preventionist acknowledged the inaccuracies in tracking and trending reports. There were no interventions or plans to prevent future UTIs or sepsis for this resident. Another resident, #46, was discharged from the hospital with antibiotics, but this was not tracked on the facility's antibiotic tracking sheet. The Infection Control Preventionist, who works part-time, reported that the tracking system was unreliable, with data disappearing after a few days, and that antibiotics administered over weekends were not followed up. Additionally, other residents were prescribed antibiotics without cultures or qualifying symptoms, contrary to the facility's policy to follow McGeer's Criteria for antibiotic stewardship.
Resident Dignity Compromised by CNA's Conduct
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred when the CNA entered the resident's room and engaged in a verbal altercation with the resident. The CNA asked the resident, 'Why you mean muggin' me?' which led to an argument between the two. The resident responded by telling the CNA to 'get over himself,' to which the CNA reacted by jumping in the air and stating, 'I just got over myself.' The resident then mentioned she would write up the CNA, who replied, 'Good, can't wait. I see flaming daggers come out of your eyes.' The resident later reported that the CNA insulted her intellect and injury, although she did not provide further details to avoid stirring up problems. This interaction demonstrated a lack of respect and dignity towards the resident, contributing to the deficiency noted in the report.
Failure to Implement Adequate Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement appropriate care plan interventions for two residents, leading to deficiencies in their care. Resident #6, who has diagnoses of morbid obesity, dementia, and mixed incontinence, was found to have three pressure ulcers on her left lateral foot during an observation. Despite being at risk for pressure ulcers, her care plan did not include a focus on active prevention or management of pressure ulcers or leg contractures. The care plan only included general interventions such as assessing postural alignment and encouraging the use of pressure-relieving boots, which were not sufficient to address her current condition. Resident #39, with diagnoses of dementia, cerebrovascular disease, and chronic kidney disease, experienced frequent urinary tract infections and had a history of urethral strictures. The review of his care plan revealed that he had 18 episodes of incontinence over a 30-day period, yet his care plan did not adequately address his toileting needs. The care plan indicated that he was not able to leave on the toilet and required stand-by assistance with a wheeled walker and gait belt, but it lacked specific interventions to manage his incontinence effectively.
Failure to Revise Care Plan for Resident with Weight Changes
Penalty
Summary
The facility failed to revise and implement a personalized care plan for a resident, identified as R17, who experienced significant weight changes. R17 was admitted with diagnoses including Congestive Heart Failure (CHF) and Morbid Obesity and was cognitively intact with a BIMS score of 14 out of 15. Despite R17's expressed desire to lose weight and the facility's documentation of weight increases ranging from 7.5% to 12.9%, the care plan was not updated to include interventions such as small meal portions, which R17 had requested. The care plan had not been revised since July 2023, and the interventions listed were generic and did not address R17's specific needs or the documented weight gain. During an interdisciplinary care conference, the facility's staff, including nursing, social work, and a registered dietician, documented R17's obesity and attributed her weight gain to CHF and medications without involving R17 in the discussion or considering her input. The care conference documentation lacked a plan to revise the care plan with measurable or personalized goals or interventions, despite the significant weight gain noted in the medical record. As of the survey exit, no additional information or corrective actions were provided by the facility.
Failure to Ensure Continuity of Care for Resident with Frequent UTIs
Penalty
Summary
The facility failed to ensure continuity of care for a resident with frequent urinary tract infections (UTIs), leading to a deficiency in quality of care. The resident, who has a history of dementia, cerebrovascular disease, chronic kidney disease, benign prostatic hyperplasia, and urethral strictures, was admitted to the facility and experienced multiple UTIs. Despite being seen by urology and having a plan for cystoscopy and kidney ultrasound, there was no follow-up documentation or planned interventions to address the frequent UTIs and prevent further complications such as sepsis. The resident's medical records revealed numerous antibiotic orders for UTIs, but there was a lack of comprehensive care planning for urinary strictures or frequent UTIs. The care plan did not focus on these issues, and there was no documentation of the root cause of the frequent UTIs. Additionally, the resident experienced episodes of incontinence, and the care plan indicated a need for assistance with toileting, which was not consistently documented or followed through by the staff. Interviews with the Infection Control Preventionist and the Director of Nursing highlighted gaps in the resident's care, including the absence of urology consultation results and inadequate documentation of fluid intake. The facility's failure to implement a comprehensive care plan and follow up on urology recommendations contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and preferences.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as R6. R6, who has diagnoses of morbid obesity, dementia, and mixed incontinence, was admitted to the facility and was at risk for pressure ulcers. Despite this, the facility did not follow physician orders or accurately assess and document the resident's condition. On a specific date, a skin assessment revealed two Stage II pressure wounds on R6's left ankle and foot. However, the treatment orders to cleanse and dress these wounds were not implemented until three days after the provider's assessment. Additionally, the resident was observed without the required dressings, and the staff failed to notify the nurse of the missing dressings. The care plan for R6 did not include a focus on active pressure ulcers or leg contractures, and interventions such as the use of pressure-relieving boots were not effectively implemented. Observations showed that R6 was left in the same position for extended periods, and the staff reported difficulties in repositioning due to the resident's contractures. The Director of Nursing confirmed that the skin assessments were inaccurate and that the care plan did not reflect the necessary interventions. The facility's policy on skin assessment and treatment was not adhered to, as evidenced by the lack of regular skin inspections and failure to implement pressure-relieving strategies.
Failure to Provide Timely Incontinence Care and Document MASD
Penalty
Summary
The facility failed to provide timely incontinence care and appropriate documentation and treatment for moisture-associated skin damage (MASD) for a resident with morbid obesity, dementia, and mixed incontinence. The resident, who is always incontinent of bowel and bladder, was observed in a wet Broda chair with a saturated sling and brief, emitting a strong urine smell. The resident's skin was red, macerated, and blanchable, with excoriated areas on the left upper thigh. The Certified Nursing Assistant (CNA) did not apply barrier cream after providing peri care, citing a lack of availability, and reported that the resident should be toileted every two hours, although this was not consistently done. The Treatment Administration Record (TAR) indicated orders for barrier cream application every shift, but the Care Plan lacked interventions for MASD. The resident was toileted only 2-4 times a day, with gaps of 10-12 hours between toileting. The Director of Nursing (DON) stated that residents should be toileted at least every two hours and that staff should report new skin conditions and apply barrier cream as needed. The facility's policy requires regular skin assessments and the application of skin barrier ointment with incontinence care, but these measures were not adequately implemented for the resident.
Failure to Notify Medical Provider of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that significant changes in weight for two residents were reviewed by a medical provider. Resident R30 was admitted with diagnoses including dementia and weakness. Her weight decreased from 203.2 pounds to 184.1 pounds over a period of approximately one month, indicating a significant weight loss. Despite this, there was no documentation in the electronic medical record (EMR) that the weight loss was reviewed by a medical provider. The Director of Nursing confirmed that the weight loss should have been referred to a medical provider for review. Resident R17, who was admitted with diagnoses including congestive heart failure and morbid obesity, experienced weight increases ranging from 7.5% to 12.9% over several months. Although the resident expressed a desire to lose weight and had communicated with the Food Service Department and medical provider, there was no documentation that the medical provider was notified of these weight changes. Interviews with facility staff, including a Physician Assistant and a Registered Dietician, revealed an expectation for documentation and notification of significant weight changes, which was not met in this case.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to provide appropriate hand hygiene during incontinence care for two residents, leading to a deficiency in infection prevention and control. Resident #6, who is moderately cognitively impaired and dependent on staff for toileting, was observed receiving incontinence care from two CNAs. During the care, one CNA did not change gloves or sanitize hands after handling urine-saturated items and before touching clean surfaces and clothing. The CNA acknowledged the lapse in hand hygiene, admitting to not changing gloves or sanitizing hands during the process. Similarly, Resident #48, who has a yeast infection and is under enhanced barrier precautions, received peri care from two CNAs. One CNA used the same soiled gloves to check for barrier cream in her pockets and then proceeded to apply a new brief and touch other objects in the room without changing gloves or sanitizing hands. The CNA admitted to the oversight in hand hygiene. The facility's LPN/Infection Control Nurse confirmed that staff are required to perform hand hygiene when moving from dirty to clean surfaces, but noted that hand hygiene audits had not been conducted recently.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that 11 out of 16 residents reviewed were provided medications as ordered, resulting in medication not being given as prescribed. On the morning of October 31, 2024, an LPN administered all daily medications at once to several residents for time management purposes. This action was discovered when a resident, who was under the care of the LPN, exhibited a change in condition and was found unresponsive with a blank stare. Upon investigation, it was revealed that the medications for the residents in the LPN's care were missing from the medication carts. The incident involved multiple residents, including one with Parkinson's disease, psychotic disorder, and dementia, who was sent to the hospital for evaluation after receiving an overdose of medications. Another resident with diabetes and schizoaffective disorder experienced hypoglycemia after receiving insulin too early, before breakfast was served. The facility's investigation found that the LPN had given all scheduled medications for the day at once, which was not in accordance with the prescribed times. Interviews with staff revealed that the LPN had previously been educated on the potential harm of administering medications all at once but continued the practice. The Director of Nursing was not informed of a similar incident that occurred earlier in the month until the more severe incident on October 31. The LPN admitted to the error and resigned following the incident, acknowledging that the action was not done with malicious intent but rather as a misguided attempt at time management.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of mental and verbal abuse in a timely manner to the state survey agency for one resident, resulting in allegations of abuse not being reported accurately and completely. The resident, who was cognitively intact, reported that a nurse yelled at her, intimidated her, and made threatening remarks. The resident felt scared and intimidated by the nurse's behavior, which included a statement that the nurse could hit her if she wanted to and that the resident could be put outside for her husband to pick up. The Director of Nursing (DON) was informed of the allegations but was not aware of the full extent of the resident's claims, including the threats made by the nurse. The DON acknowledged the situation and stated that the nurse had been educated, but there was no documentation of an investigation or follow-up with the resident. The Nursing Home Administrator (NHA) also became aware of the allegations but did not initiate an investigation until prompted by the surveyor. The NHA expressed difficulty in determining the specifics of the allegations due to the resident's varying statements. The facility's records did not contain any documentation of the resident's allegations or any investigation into the matter. The facility eventually reported the incident to the state survey agency, but the report was incomplete and did not include all the allegations made by the resident. The facility's policies required immediate reporting of abuse allegations, but this was not adhered to, resulting in a delay in addressing the resident's concerns.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain complete, timely, and accurate medical records for one of its residents, identified as R4. The deficiency was identified during a review of R4's medical records and interviews with facility staff. R4, a resident with dementia and severe cognitive impairments, was involved in an incident on April 4, 2024, where she became agitated and physically aggressive towards other residents. Despite the incident, there was no documentation in R4's medical records about the event, except for a vague note by a social worker that did not specify the nature of the occurrence. The Director of Nursing (DON) acknowledged the lack of detailed documentation regarding the incident. The DON stated that her interdisciplinary documentation note from April 5, 2024, was intended to address the incident, but it did not explicitly mention the resident-to-resident altercation. The note focused on R4's increased agitation related to bowel movements and constipation, which was discovered during the investigation of the incident. The DON admitted that her documentation had been lacking in detail and was working on improving it. The absence of proper documentation in R4's medical records highlights a failure in maintaining accurate and complete records, which is essential for effective communication among healthcare providers. The American Nursing Association emphasizes the importance of clear, accurate, and accessible documentation as a critical element of safe and quality nursing practice. The lack of documentation could potentially hinder the ability of healthcare providers to make informed decisions and ensure high-quality care for residents.
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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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