Grand Traverse Pavilions
Inspection history, citations, penalties and survey trends for this long-term care facility in Traverse City, Michigan.
- Location
- 1000 Pavilions Circle, Traverse City, Michigan 49684
- CMS Provider Number
- 235088
- Inspections on file
- 30
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Grand Traverse Pavilions during CMS and state inspections, most recent first.
A facility failed to follow fall-prevention care plan interventions and provide adequate supervision for three high-risk residents. One resident with orthostatic hypotension and moderate cognitive impairment was left alone in the bathroom without proper footwear, contrary to care plan directives, and fell, later being found with right hip pain and a confirmed hip fracture. Another resident with severe dementia and a history of repeated falls, on 1:1 observation, slipped off the bed while reaching for a phone, with observation showing frequently used items were not kept within reach as ordered. A third resident with multiple comorbidities and essential tremor, assessed as needing assist of one with a walker, fell when attempting to go to the bathroom without the walker, which had been left in the bathroom and not kept within reach despite care plan instructions.
A resident with depression and intact cognition reported that the NHA and two maintenance staff entered his room without knocking while he was about to eat, and that the NHA leaned over his tray, spoke loudly and angrily about his open window, repeatedly used the wrong name despite correction, and suggested he might prefer to return to his prior facility where windows could be opened. The resident described the NHA’s tone and posture as intimidating, condescending, and belligerent, and later felt uneasy and threatened about future encounters. Staff interviews and the NHA’s own written statement confirmed key elements of the interaction, and the facility’s abuse prevention policy includes protection from humiliation, harassment, and threats of punishment.
A resident admitted for post–joint replacement aftercare, who was self-responsible for decisions and totally dependent on two staff for dressing, reported repeatedly waking early, using the call light, and clearly stating a preference to be assisted up between 6:00 a.m. and 7:00 a.m. Staff delayed getting the resident up until much later, told the resident they did not get people up that early or that the resident was not a priority, resulting in a missed shower, an episode of bowel and bladder incontinence, and a cold breakfast after being sent for a weight check. The resident was visibly upset and expressed frustration that staff would not listen, while review of the Kardex showed dressing needs but no documentation of the resident’s preferred wake-up time, despite leadership stating such preferences should be recorded and staff are educated on resident rights and choices.
The facility failed to consistently honor resident food preferences and special dietary needs, leading to repeated frustration with meals. Several residents reported frequently receiving food they did not want, did not order, or could not have due to medication-related restrictions, and having to send trays back and wait for corrections. Staff interviews revealed ongoing problems with the meal-ticket system, including staff not discussing choices with residents, not returning completed tickets to the kitchen, and the kitchen defaulting to main meals when tickets were missing or incomplete, despite policies requiring timely collection and periodic review of food preferences.
A resident with COPD and dementia experienced acute respiratory distress after an oxygen tubing disconnection during toileting, with oxygen saturation dropping to 53%. Staff delayed contacting the on-call provider for 53 minutes after failing to reach telehealth, and did not document monitoring or update the family for about three hours. The resident was eventually transferred to the hospital in severe hypoxia and later died.
A resident with COPD and chronic hypoxic respiratory failure was transported to a medical appointment with only one portable oxygen tank, which ran out during the visit. No backup oxygen was available, and the resident's oxygen saturation dropped to 70% while waiting for supplemental oxygen. Staff interviews revealed confusion about oxygen therapy protocols, and the resident was transported with a nasal cannula at a flow rate above policy limits, leading to inadequate respiratory support.
A resident with multiple comorbidities developed and experienced worsening of two stage 4 pressure ulcers, including one caused by improper wound vac tubing placement. The facility failed to prevent new pressure injuries and did not ensure proper wound care, equipment maintenance, or reassessment, resulting in severe pain, infection, and repeated debridement.
A resident with multiple fractures did not receive prescribed morphine for pain management when the facility ran out of medication over a weekend. Staff were unable to obtain a timely refill or substitute, resulting in the resident experiencing severe, unrelieved pain and requiring transfer to the ED for pain control. Documentation and staff interviews confirmed that medication reordering protocols were not followed, leading to the deficiency.
Multiple residents experienced prolonged call light response times and unmet care needs due to insufficient staffing, with reports of waiting up to an hour for assistance with toileting, meals, and other essential needs. Residents described episodes of incontinence, frustration, and having to seek help from non-clinical staff or attempt tasks independently despite risks. Staff interviews confirmed ongoing staffing shortages and challenges in meeting resident needs.
Surveyors identified several sanitation failures in the kitchen, including dirty food-contact surfaces, improper storage of utensils, unlabeled chemical bottles, an inaccessible handwashing sink, and unclean physical facilities. These deficiencies were observed during kitchen inspections and were not in compliance with FDA Food Code standards.
The facility failed to maintain an effective water management program to reduce the risk of Legionella and other pathogens, as evidenced by unused water lines, discolored water, and lack of comprehensive flushing and disinfection testing. Additionally, infection prevention practices were not followed for two residents, including improper storage of a urinal on an overbed table next to food and lapses in PPE and hand hygiene during medication administration.
Residents were observed waiting for extended periods in multiple dining halls without drinks or timely meal service, with limited staff available to assist. Interviews and resident council minutes confirmed ongoing concerns about delayed food and beverage service, leading to resident frustration and a lack of resolution over several months.
Multiple residents reported dissatisfaction with the grievance process, particularly regarding missing personal items, as their concerns were not documented, tracked, or resolved in a timely manner. Staff interviews revealed a lack of awareness about grievance reporting procedures, and review of meeting minutes showed ongoing resident concerns were not followed up on or communicated back to residents.
Surveyors found unsecured medications in a public hallway, loose tablets in medication carts, and an expired insulin pen that was not removed after discontinuation. An RN was observed discarding unidentified medications into a regular trash receptacle instead of using the facility's designated disposal system. Staff interviews and policy reviews confirmed these actions were not in accordance with facility protocols for medication security and disposal.
A resident with severe cognitive impairment and a history of aggressive behaviors was repeatedly involved in physical altercations with other residents. Despite a care plan outlining specific interventions to prevent such incidents, staff did not consistently implement these measures, resulting in multiple episodes of resident-to-resident abuse and harm.
The facility did not provide required written notifications of transfer, discharge, or bed hold policies to two residents who were sent to the hospital. Documentation was missing for one resident's transfer, and another resident's transfer was not recorded on the ombudsman notification log, indicating failures in the facility's notification and documentation processes.
A resident with Alzheimer's Disease was involved in a behavioral incident after another resident entered her room, but the care plan was not updated to address this event. The intervention of placing a stop sign on the door was ineffective, as the resident often removed it, and observations showed it was not consistently in place. Staff acknowledged the intervention's ineffectiveness, and there was no documentation of revised interventions following the incident.
A resident with multiple chronic conditions was given a significantly higher dose of lorazepam than ordered, resulting in drowsiness and lethargy. The error stemmed from confusion between two residents' medication orders and was compounded by inconsistent documentation in the MAR and controlled substance log. Following the incident, required monitoring of vital signs was not completed for several shifts, and no nursing progress notes documented follow-up on the error.
A resident with cognitive impairment and impulsive behavior was not adequately supervised during ADL care, leading to a fall from the bed while being dressed by a CNA. The CNA turned away momentarily, resulting in the resident falling and sustaining multiple injuries, including a hematoma and bruising. Staff interviews confirmed the lapse in supervision and improper post-fall handling.
Two residents requiring respiratory care did not have their oxygen tubing, CPAP masks, and nebulizer equipment stored or cleaned according to facility policy. Oxygen tubing was repeatedly found on the floor without protective covering, and a nebulizer with condensation was left on a bedside table. Staff confirmed that equipment should be stored in bags and cleaned after use, but these procedures were not followed.
A resident with PTSD was admitted and re-admitted without proper identification or documentation of trauma triggers, and no individualized care plan interventions were developed to address trauma-informed care. Staff were unaware of the resident's specific triggers, and required assessments and care planning were not completed as outlined in facility policy.
A resident admitted for rehabilitation after multiple fractures was left without prescribed morphine for pain management when the facility failed to reorder the medication in advance. The LPN discovered the shortage over a weekend, and attempts to substitute with oxycodone were unsuccessful due to limited supply. The resident was sent to the ED for pain control, experiencing significant discomfort and agitation as a result. Staff interviews confirmed that established procedures for medication reordering and emergency pharmacy services were not followed.
The facility did not ensure that physicians addressed and documented responses to pharmacist recommendations from monthly Medication Regimen Reviews for two residents. In both cases, pharmacist requests for medication clarification, dose reduction, and laboratory testing were not acted upon or documented by the physician in the clinical record, and the facility lacked a system to monitor physician follow-up as required by policy.
Two residents with documented needs for adaptive dining equipment, including non-slip dycem, did not receive this equipment during observed meals, despite care plans and tray cards specifying its use. Staff interviews and record reviews revealed a lack of communication between departments, resulting in outdated tray card instructions and failure to provide the necessary adaptive equipment, causing increased difficulty with food consumption and independent eating.
A resident admitted for rehabilitation with multiple chronic conditions did not receive a pneumococcal vaccine as recommended, despite documented consent and facility policy requiring timely administration. Review of records showed the vaccine was overdue and had not been given during the resident's stay, contrary to the facility's stated procedures.
Two residents with multiple comorbidities were not administered the COVID-19 vaccine despite being overdue and having provided consent upon admission. Facility records and the Michigan Care Improvement Registry confirmed that no vaccine was given during their stay, contrary to facility protocol and CDC recommendations.
A resident admitted for rehab after knee replacement surgery experienced severe constipation due to inadequate bowel assessments and management by the facility. Despite complaints of abdominal pain, the facility did not follow its bowel management protocol, leading to the resident's hospitalization and subsequent death from ischemic colitis, septic shock, and organ failure.
A facility failed to protect residents from verbal abuse and neglect by a CNA. A resident with severe cognitive impairment reported that the CNA threw a brief on the bed and left without assisting. Another resident, with moderate cognitive impairment, was not thoroughly cleaned after toileting and was told to speak to her nurse in the morning. A third resident, with intact cognition, was left in wet bedding after the CNA swatted her hand away and told her to be quiet. These incidents were confirmed by other staff members.
A resident with severe cognitive impairment was moved to a secured memory care unit without prior written notice to the resident or their representative. The move was directed by the DON after the resident wandered from their room, but the usual process of obtaining consent was not followed, leading to confusion and displeasure from the resident's spouse.
A resident with liver cell carcinoma was subjected to verbal and mental abuse by a former NHA, who intimidated the resident for going outside unattended. Witnesses confirmed the NHA's intimidating demeanor, leaving the resident feeling embarrassed and fearful. The facility's investigation substantiated the complaint, and the NHA is no longer employed.
A resident with severe cognitive impairment was inappropriately placed in a secured memory care unit shortly after admission, despite not exhibiting behaviors warranting such a move. The DON directed the transfer after the resident was found outside his room twice, attributed to confusion. Staff and the resident's spouse confirmed the move was atypical and not based on clinical criteria or an emergent need. The facility failed to adhere to its policy on resident care rights, lacking documented justification or ongoing assessment for the placement.
A facility failed to report an alleged abuse incident involving a former NHA who verbally and mentally abused a resident. The ADON witnessed the incident and reported it to the DON, who did not report it to the State Agency, perceiving it as a rights violation rather than abuse. The incident was only reported months later after a complaint was filed, violating the facility's abuse prevention policy.
A facility failed to thoroughly investigate an allegation of verbal abuse when a resident was called a derogatory name by a housekeeping staff member. Despite the resident being cognitively intact and expressing feelings of being demeaned, the DON did not conduct a comprehensive investigation as required by the facility's policy. Witness statements confirmed the incident, but there was no formal interview with the resident or documentation in the medical record, leading to a deficiency.
A resident with a history of stroke and anemia experienced shortness of breath and black tarry stools, indicating a potential gastrointestinal bleed. Despite these symptoms, an LPN did not contact the on-call physician, leading to a delay in treatment and the resident's subsequent death. The facility's policy on change in condition was not followed, and the resident's vital signs were not compared to baseline. The Medical Director confirmed that the symptoms warranted immediate medical evaluation.
A resident with type two diabetes and moderate cognitive impairment did not receive timely A1c tests as ordered by a physician, and their diabetes medication was discontinued without informing the durable power of attorney. This led to severe hyperglycemia, requiring hospitalization. The resident later passed away while on hospice care. The facility's policy to provide diagnostic services per physician's orders was not followed.
A resident with moderate cognitive impairment had their diabetes medication discontinued without informing their DPOA, despite facility policy requiring notification of significant treatment changes. The DON confirmed the oversight, which contradicted standard practice.
The facility failed to notify a physician and conduct timely assessments for a resident with low blood pressure, leading to the resident's death. Additionally, the facility delayed administering IV fluids to another resident with respiratory illness, resulting in hospitalization and death. These deficiencies highlight significant lapses in following medical protocols and timely care.
The facility failed to follow professional standards for food service safety. Kitchen staff did not properly clean transport carts after removing soiled trays, and a food service worker inadequately sanitized the carts. Additionally, a worker contaminated his hands by touching a trash container lid before returning to the serving line, violating FDA handwashing protocols. These practices risk foodborne illness among residents.
The facility did not effectively implement its QAPI program, failing to include adverse events such as unexpected deaths in its review process. The RN/Staff Educator overseeing QAPI confirmed that these events were discussed in IDT meetings but not in QAPI, and was unable to explain how medical errors or adverse events were managed. The facility's policy indicated that adverse events should be reviewed and communicated to the QAPI Committee, but this was not done.
The facility failed to provide written notifications to residents and/or their representatives for hospital transfers. This deficiency was identified for four residents, as confirmed by EMR reviews and staff interviews. The facility's policies require written notifications, which were not followed in these cases.
The facility failed to provide written notification of the bed hold policy to two residents or their representatives during hospital transfers. A resident was transferred to an acute care hospital, and interviews confirmed that no bed hold policy was issued. Another resident was hospitalized, and the EMR did not indicate that a bed hold policy was provided. Interviews verified that the facility's policy, which requires informing the responsible party and activating a Bed Hold Form, was not followed.
A facility failed to create a comprehensive care plan for a resident using psychotropic medications, lacking specific targeted behaviors and non-pharmacological interventions. The resident had severe cognitive impairment and was prescribed lorazepam for anxiety. The care plan did not meet the facility's policy requirements, leading to potential unnecessary medication use.
Two residents in the facility were not provided with prescribed orthopedic braces, leading to potential complications. One resident, recovering from spinal surgery, was observed without a cervical collar despite orders to wear it at all times. Staff were unaware or misinformed about the requirement. Another resident, with contracted hands, was not wearing palm protectors as recommended. The facility's policies on orthotic devices were not followed, indicating a lack of staff education and communication.
The facility failed to prevent unsafe wandering and elopement for three residents with severe cognitive impairments, resulting in one elopement and continued unsafe supervision. Despite care plans with interventions, staff were unable to effectively supervise and redirect residents, leading to wandering into other residents' rooms and attempts to leave the facility. Staffing challenges were acknowledged by the nursing leadership.
A resident with diagnoses of pneumonia and sleep apnea was not consistently provided with supplemental oxygen as per physician orders, leading to potential respiratory complications. The facility had contradictory orders for continuous oxygen and weaning, without specific saturation parameters, causing confusion among staff and inconsistent care.
The facility failed to ensure MRRs were addressed by the physician for two residents. One resident's antianxiety and melatonin dosage recommendations were not documented by the physician, and another resident's AIMS assessments were delayed despite pharmacist recommendations. The DON confirmed the lack of follow-up and documentation, contrary to facility policy.
A facility failed to document targeted behaviors and use non-pharmacological interventions before administering PRN lorazepam to a resident with dementia and anxiety. The resident's MARs showed multiple administrations of the medication without documented reasons or attempts at non-pharmacological interventions, contrary to facility policy. The ADON confirmed the lack of required documentation and intervention attempts.
Three residents experienced delays in receiving dental care, leading to a deficiency. One resident had a broken tooth and was unsure when she would see a dentist, another suffered from tooth pain for over two weeks without a scheduled visit, and a third lost significant weight due to ill-fitting dentures. The facility failed to arrange timely dental appointments, despite being aware of these issues.
A resident experienced discomfort in her wheelchair due to the facility's failure to conduct an occupational therapy evaluation and treatment as recommended and ordered. Despite a progress note and physician order in the EMR, the necessary OT evaluation was not performed, leading to the resident's discomfort.
A facility failed to ensure effective communication and coordination with a hospice provider for a resident with Alzheimer's and severe cognitive impairment. The resident's DPOA reported a lack of communication about the hospice care being provided. Review revealed only two documented hospice visits in August, despite the care agreement requiring regular documentation and coordination. The ADON and DON confirmed the lack of additional hospice documentation, highlighting a deficiency in communication and coordination of care.
Failure to Implement Fall-Prevention Interventions and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of appropriate fall-prevention interventions for three residents, despite identified fall risks and existing care plan directives. One resident with weakness, malaise, orthostatic hypotension, and moderate cognitive impairment (BIMS 12/15) was care planned as high risk for falls with specific interventions including not leaving the resident alone in the bathroom and ensuring appropriate footwear during ambulation. On the date of the incident, a CNA ambulated this resident to the bathroom with a gait belt; the resident pulled down her own pants and told the CNA he could leave. After the CNA began to close the door, he heard a loud noise and found the resident on the bathroom floor, with the RN later documenting that the resident reported hitting her head and having right hip pain. The record notes the resident did not have proper footwear on to ambulate, and the care plan intervention to not leave the resident alone in the bathroom was not followed. Another resident with neurocognitive disorder with Lewy Bodies, major depressive disorder, bipolar disorder, PTSD, repeated falls, and severe cognitive impairment (BIMS 5/15) had been care planned as high risk for falls, with interventions including keeping frequently used items within reach and providing 1:1 supervision due to poor safety awareness. While on 1:1 observation, this resident slipped off the bed while reaching for a phone, as documented by a CNA witness statement and an incident report. Later observation showed the resident lying half on and half off the bed, with the tray table about 12 inches from the bed and no phone on the tray table, indicating that frequently used items were not within reach as specified in the care plan. A third resident with multiple medical conditions including metastatic cancer, squamous cell carcinoma, DM II, CKD stage 4, BPH, and essential tremor was assessed as moderately at risk for falls and later documented by therapy as requiring assistance of one person to walk with a walker. The care plan identified the resident as high risk for falls related to poor safety awareness, with interventions such as ensuring all necessities were within reach and encouraging use of proper ambulatory assistive devices. A fall report indicated that staff found this resident on the floor next to the bed after he attempted to get up to go to the bathroom without his walker, which had been left in the bathroom. The documentation noted that the resident sometimes ambulated with a walker without assistance, but at the time of the fall the walker, identified as a necessary assistive device, was not within reach, contrary to the care plan intervention. As a result of these failures, one resident sustained a right hip fracture requiring hospitalization and surgical intervention.
Failure to Treat Resident with Dignity and Respect During Administrator Interaction
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident with dignity and respect during interactions with the Nursing Home Administrator (NHA). The resident, who had a diagnosis of depression and a BIMS score of 15/15 indicating normal cognition, reported that the NHA and two maintenance staff entered his room without knocking while he was about to eat. The resident stated the NHA leaned over his food tray, spoke to him in a loud, angry, and condescending tone about his window being open, and repeatedly called him by his roommate’s name even after being corrected. The NHA questioned the resident about his prior facility and, according to both the resident and the NHA’s own written statement, suggested that if the resident wanted his window open, he might prefer to return to his former facility. The resident perceived the NHA’s posture and tone as intimidating and felt the NHA was trying to have him removed from the facility. Interviews with staff and review of the facility’s investigation corroborated that the resident experienced the interaction as loud, aggressive, and disrespectful. A CNA reported that the resident, who was usually joking with staff, appeared emotionally different after the incident and told her the NHA was loud and aggressive, would not use his correct name, and leaned over his table and yelled at him. The social worker later learned the resident felt the NHA spoke to him in an intimidating, angry, and condescending way, and the ADON reported the resident told her he did not like how the NHA had spoken to him. In a follow-up interview, the resident stated he felt uneasy about being yelled at again or being called by the wrong name if he saw the NHA. The facility’s Abuse Prohibition and Prevention Program policy includes protection from humiliation, harassment, and threats of punishment, which contrasts with the resident’s description of the NHA’s conduct.
Failure to Honor Resident’s Morning Routine and Care Preferences
Penalty
Summary
The deficiency involves the facility’s failure to honor and support a resident’s stated preference for morning wake-up and assistance times, despite the resident being self-responsible for medical and financial decisions. The resident was admitted with aftercare needs following joint replacement surgery and required total assistance from two staff for dressing. During interviews, the resident reported routinely waking between 6:00 a.m. and 7:00 a.m., activating the call light to get dressed and ready for the day, and having clearly communicated this preferred schedule to staff. Over a weekend, staff did not assist the resident to get up and dressed until approximately 9:00–9:30 a.m., and staff told the resident they did not get people up that early or that the resident was not a priority. The resident further reported missing a scheduled shower due to delays in assistance and experiencing an episode of bowel and bladder incontinence over the weekend because staff did not get him up in time, which he described as embarrassing. Bowel and bladder records confirmed an incontinent episode on 2/22/26. In a follow-up interview, the resident again stated he woke around 6:30 a.m. and staff refused to get him up, with assistance not provided until 7:45 a.m.; by the time he was ready, his breakfast had arrived but was then left to get cold while he was sent for a weight check. The resident expressed visible upset, frustration, and a lack of understanding as to why staff would not help or listen to his preferences. Review of the Kardex showed documentation of his dependence on staff for dressing but did not include his preferred time to get up in the morning, despite the DON’s statement that such preferences should be recorded there and staff education on resident rights and choices.
Failure to Consistently Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The deficiency involves the facility’s failure to consistently honor resident food preferences and dietary needs for three residents reviewed for nutritional services. One resident reported that the food was "horrible," stating that they did not receive what they requested and that alternates arrived late, causing frustration. Another resident stated that they often received food they did not want or did not order, requiring them to send the tray back and wait for the correct meal, which they also described as frustrating. A third resident reported that the kitchen did not always follow his food preferences and that he continued to receive spinach on his tray despite being unable to have it due to vitamin K content and his medications, leading him to send meals back when they contained items he did not like or could not have. Staff interviews and policy review further described how the facility’s meal-ordering system contributed to these issues. The Nutrition Assistant and Food Director explained that resident food likes/dislikes and preferences are obtained on admission and used to create individualized meal tickets, which are supposed to be updated yearly and used for advance ordering. They acknowledged ongoing problems with floor staff not returning meal tickets to the kitchen or circling items without actually discussing choices with residents, resulting in the kitchen preparing either what was circled or the main meal, regardless of resident preference. The Education Director stated that staff are educated to pick up and complete food order tickets with residents and return them promptly, but confirmed there have been instances when tickets are not returned in time and the kitchen prepares the main meal, requiring a later call for an alternate. Facility policies indicated that food preferences should be obtained within 72 hours of admission and reviewed periodically, and that the food service department is responsible for providing nourishing, palatable diets that meet residents’ nutritional and special dietary needs.
Failure to Monitor and Respond to Change in Condition Resulting in Delayed Treatment
Penalty
Summary
The facility failed to effectively monitor, report, and respond to a significant change in condition for a resident with a history of COPD, lung cancer, and dementia. The resident was admitted with orders for continuous oxygen and was dependent on two staff for transfers and toileting. In the early morning hours, a CNA independently transferred the resident to the toilet using a mechanical lift, during which the resident became acutely short of breath with an oxygen saturation of 53%. It was later discovered that the oxygen tubing had become disconnected, and after reconnection, the resident's oxygen saturation only improved to 87-89% despite increased oxygen flow and administration of an albuterol inhaler. Following this event, the RN attempted to contact a telehealth provider for further medical direction but did not receive a response for 53 minutes. During this time, the resident's oxygen saturation remained unstable, dipping as low as 78%. The RN eventually contacted the on-call provider, who gave orders for comfort medications and to maintain high-flow oxygen. There was no documented monitoring of the resident's symptoms or vital signs for approximately three hours between the initial incident and the eventual transfer to the hospital. Interviews revealed that care assistants provided only verbal updates, and the family was not kept informed of the resident's ongoing condition during this period. The resident was ultimately transferred to the hospital after continued hypoxia and respiratory distress, where she was admitted under pulmonary critical care and later passed away. The facility's telemedicine policy required prompt physician contact in the event of a change in condition, and both the DON and the on-call provider stated that the delay in contacting a provider was inappropriate. The lack of timely monitoring, documentation, and communication with both medical providers and the family contributed to the delayed medical intervention.
Failure to Provide Adequate Oxygen Therapy During Resident Transport
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), chronic hypoxic respiratory failure, and a history of lung cancer was transported to an orthopedic appointment with only one portable oxygen E-cylinder, despite a physician order for continuous oxygen at 6-8 liters per minute (LPM). During the appointment, the resident's oxygen supply was depleted, and no backup oxygen tank was available on the transport vehicle. The resident's oxygen saturation dropped to around 70% while waiting for supplemental oxygen, and staff at the orthopedic clinic had to assist until a replacement tank was retrieved from the facility. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding oxygen therapy during transport. The certified nursing assistant (CNA) responsible for preparing the resident believed that backup tanks were not permitted per facility policy, while the registered nurse (RN) was unaware of the need for a backup tank and underestimated the rate at which the oxygen would be consumed at the prescribed flow rate. The transport driver confirmed that the vehicle was not equipped with additional oxygen tanks and had to return to the facility to obtain one. Review of facility policies and vendor documentation indicated that an E-tank at a 6 LPM flow rate would last approximately 75 minutes, and that a nasal cannula should not be used for flow rates above 6 LPM. The resident was transported with a nasal cannula set at 8 LPM, contrary to policy, which requires a simple face mask for higher flow rates. The facility's failure to provide adequate oxygen supply and appropriate delivery equipment during transport resulted in the resident experiencing severe hypoxemia and distress.
Failure to Prevent and Manage Stage 4 Pressure Ulcers
Penalty
Summary
A deficiency was identified when a resident developed and experienced progression of two stage 4 pressure ulcers, one on the left ischium and another on the scrotum, despite being under the care of the facility. The scrotal pressure ulcer was attributed to improper placement of wound vac tubing, which was observed pressing against the resident’s skin. Documentation and staff interviews confirmed that the wound vac was not applied correctly, and the tubing was not properly bridged, resulting in a deep tissue injury that progressed to a stage 4 pressure ulcer. The resident experienced severe pain during dressing changes and required wound debridement and antibiotics due to infection. The resident had a history of significant medical conditions, including hypertension, diabetes mellitus, depression, spastic hemiplegia, and a pre-existing stage 4 pressure ulcer. Despite these risk factors and a care plan that included interventions to prevent skin breakdown and ensure proper use of medical devices, the facility failed to prevent the development of a new pressure ulcer and the worsening of existing wounds. Wound assessments over several months documented that the wounds were not healing and, in some cases, were deteriorating, with exposed muscle and bone, tunneling, and repeated need for debridement. Further review revealed that the resident’s pressure-relieving equipment, such as a ROHO cushion, was found deflated and had not been properly maintained or reassessed by therapy staff after the development of the pressure injury. Occupational therapy notes did not include a reassessment of the wheelchair or cushion system, and wound care documentation indicated improper dressing techniques, including the use of creams that may have contributed to maceration. Staff education and performance issues related to wound vac application were also noted, but the deficiency centers on the failure to prevent and properly manage pressure ulcers as required by facility policy and the resident’s care plan.
Failure to Provide Prescribed Pain Management
Penalty
Summary
The facility failed to provide prescribed pain management for a resident admitted for rehabilitation following multiple fractures sustained in a motor vehicle accident. The resident had orders for both extended-release and immediate-release morphine to manage moderate to severe pain. Over a weekend, the facility ran out of the resident's prescribed morphine, and no additional medication was available in the medication cart or back-up supply. The resident consistently requested pain medication as ordered, but staff discovered there were no refills remaining and no in-house provider was available to write a new prescription. Attempts to substitute with oxycodone were unsuccessful due to insufficient supply, and the pharmacy could not deliver the required medication until after the weekend. As a result, the resident experienced unrelieved, severe pain, with documented pain levels frequently at 10 out of 10. The resident was transferred to the emergency department for pain management due to the facility's inability to provide the prescribed medication. Upon return, the resident continued to report high pain levels and exhibited signs of distress, agitation, and anxiety related to the uncertainty of receiving pain medication. The resident expressed dissatisfaction and concern for his safety due to the lack of pain control. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the medication should have been reordered before supplies were depleted. Facility policy required each shift to maintain adequate medication supplies and reorder as needed, but this process was not followed, resulting in the resident's pain going untreated and necessitating transfer to the hospital for pain relief.
Insufficient Staffing Leads to Delayed Call Light Responses and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times and unmet care needs for multiple residents. Resident council minutes and confidential group interviews revealed ongoing concerns about delayed responses, particularly at night and during early mornings, with residents reporting wait times ranging from 5 to 45 minutes or more. Residents described episodes of incontinence, frustration, and instances where staff were unable to assist due to being occupied with other duties, such as feeding other residents. Several residents reported having to wait for assistance with toileting, meals, and other essential needs, with some resorting to calling out to non-clinical staff for help or attempting to manage their needs independently despite risks. Specific cases included a resident with left-sided hemiplegia following a stroke who required moderate to maximum assistance for transfers and toileting. This resident reported an incident where her call light went unanswered for approximately two hours, leading her to call 911 for help. Documentation confirmed the event, and the resident was subsequently provided with alternative means to contact staff. Another resident with a history of falls and a recent elbow fracture reported waiting over 20 minutes for call light responses and often attempted to use the bathroom independently due to urgency, despite being at high risk for falls and requiring assistance per her care plan. Facility call light logs corroborated multiple instances of response times exceeding 25 minutes for this resident. A third resident, dependent on staff for toileting and always incontinent, reported waiting at least 45 minutes for assistance, resulting in prolonged exposure to soiled conditions. This resident also expressed concern about choking risks due to delayed help with meals. Facility records showed numerous call light response times exceeding 25 minutes for this resident, with some waits approaching or exceeding an hour. Staff interviews confirmed ongoing staffing shortages, particularly on weekends, and described situations where aides on light duty were required to assist with resident care due to insufficient staffing levels.
Multiple Food Service Sanitation Failures Identified in Kitchen
Penalty
Summary
Surveyors observed multiple failures to maintain food service safety and sanitation standards in the facility's kitchen. During the initial tour, the large mixer was found with an accumulation of white debris, despite being covered with a plastic bag to indicate cleanliness. The blue ice scoop holder contained black debris, and clean utensil bins and drawers had crumb debris present. The slicer, which was reportedly rarely used, had dried meat debris on the blade, and the sheet pan under the mixer, used for storing attachments and utensils, also had crumb debris. Additionally, some metal spoons were stored upright with water accumulation, and three half pans were stacked and stored wet, with water between them. Two spray bottles containing unknown solutions were found without proper labeling, and a handwashing sink was blocked by a cart full of dirty pots and pans, making it inaccessible for use. Further inspection revealed excess food and crumb debris under storage racks and along the perimeter of the walk-in cooler, with no base coving present to protect the wall-floor juncture. These findings were in direct violation of multiple sections of the 2022 FDA Food Code, including requirements for clean food-contact surfaces, proper air-drying of utensils, labeling of toxic materials, accessibility of handwashing sinks, and maintenance and cleaning of physical facilities. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Deficient Infection Control Practices and Water Management
Penalty
Summary
The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. Observations during facility tours revealed multiple unused water lines protruding from pantry and activity room walls, as well as discolored water dispensed from hopper faucets and sprays in soiled utility rooms. Some hopper spray foot pedals were turned off at the source, indicating stagnant water lines. Interviews with environmental services staff confirmed that only annual Legionella samples were taken, with no testing for free chlorine or other disinfection levels, and that hot water boilers were set below the recommended temperature for pathogen control. Facility documentation stated that irregularly used or low-flow fixtures should be flushed at least twice per week, but staff reported only flushing fixtures in certain areas, with no evidence of a comprehensive flushing protocol for all minimal-use outlets. The facility also failed to implement proper infection prevention practices and appropriate use of personal protective equipment (PPE) for two residents. One resident, who was non-ambulatory, dependent on staff for ADLs, and receiving hospice care, was observed with a stained urinal placed directly on the overbed table next to open food and drink, without a barrier. This practice was repeated over multiple observations, and staff interviews revealed that there was no care plan or documentation indicating the resident had requested the urinal be kept on the overbed table. Facility policy required urinals to be stored in a cabinet or drawer, not on the overbed table, especially near food. Additionally, staff were observed not following proper PPE and hand hygiene protocols during medication administration. An LPN was seen wearing gloves used for insulin administration out of a resident's room and handling items on the medication cart before removing gloves and performing hand hygiene. Another nurse was observed touching the rims of medication cups with bare, unwashed hands while separating them. Interviews with nursing leadership confirmed these actions were not in accordance with facility policy, which required removal of gloves and hand hygiene before leaving resident rooms and avoiding contact with the rims of medication cups.
Failure to Provide Timely and Dignified Dining Experience
Penalty
Summary
Multiple observations were made across four dining halls where residents were seated for extended periods without being provided drinks, and in some cases, without timely meal service. In Elm Dining Hall, 25 residents were observed without drinks until the meal cart arrived, and staff began distributing meals. Similar delays were noted in Dogwood, Cherry, and Birch Dining Halls, with residents waiting for both drinks and meals, sometimes for over half an hour. Staff presence was limited, with only one or a few staff members available to assist, contributing to the slow distribution of food and beverages. Interviews and resident council meeting minutes confirmed ongoing concerns about delayed meal service and lack of beverages, with residents expressing frustration and feelings of helplessness due to the wait times. The General Manager acknowledged the expectation that drinks should be provided as residents are seated but noted issues with staffing and coordination. Resident council minutes from previous months documented repeated complaints about late meal service and cold food, indicating that the problem had been ongoing and unresolved.
Failure to Promptly Resolve and Track Resident Grievances
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances, specifically for three residents who reported missing personal items. During a confidential group meeting, multiple residents expressed dissatisfaction with the grievance process, stating that concerns were not addressed in a timely manner and that they often did not receive feedback or solutions. Review of Resident Council meeting minutes over several months showed that concerns raised by residents were not followed up on or resolved, as subsequent meetings consistently recorded no old business to discuss or follow up. Specific examples included residents reporting missing items, such as clothing and blankets, to staff without any documented resolution or communication back to the residents. Interviews with staff revealed a lack of awareness and adherence to the facility's grievance reporting procedures. Several CNAs and RNs were unaware of the required forms or processes for documenting and tracking grievances related to missing items. The facility's policy on missing items did not include a mechanism for tracking or reporting grievances, nor did it specify how to keep residents informed of the status of their concerns. As a result, grievances were not consistently documented or addressed, and residents were left without resolution or updates regarding their reported issues.
Medication Storage and Disposal Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication storage and disposal practices. During an environmental tour, five loose medications were found between the seat cushions of a chair in a hallway, accessible to residents and not secured. Additionally, three medication carts on the Maple Unit and two on the Cherry Unit were reviewed, revealing loose tablets in two carts and an expired insulin pen in another. The insulin pen had been discontinued per physician order, but remained in the cart past its discard date. In one instance, an RN was observed disposing of unidentified medications from a plastic cup found in a medication cart by dumping them into a standard refuse receptacle, without knowledge of what the medications were or who they belonged to. Interviews with nursing staff and review of facility policies confirmed that medications should not be pre-set, must be prepared at the time of administration, and should be disposed of using a designated medication disposal system (Drug Buster®), not in regular trash. The facility's policies also require that medications be stored securely and only accessible to authorized personnel. The observed practices did not align with these policies, as medications were found unsecured, improperly stored, and inappropriately disposed of.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident physical abuse, resulting in harm from the reasonable person perspective for three residents. One resident with severe cognitive impairment and a history of physical and verbal behaviors was observed becoming confrontational with others in the memory care unit dining hall, attempting to take drinks and becoming upset. Staff attempted redirection, but the resident repeatedly returned to the area and continued the behavior. Incident reports revealed multiple altercations involving this resident, including being physically grabbed and pushed by other residents after entering their personal space or rooms. The care plan for this resident identified a risk for physical aggression and outlined specific interventions, such as 1:1 de-escalation and immediate separation of residents during altercations. Despite these interventions being documented in the care plan, observations and record reviews showed that the interventions were not consistently implemented. The facility's own policy required monitoring for aggressive behavior, prompt reporting, care plan updates, documentation of interventions, and psychiatric consultation as needed. However, the resident continued to be involved in multiple altercations, and staff interviews indicated ongoing issues with supervision, behavioral management, and lack of effective intervention. The facility reported several incidents of resident-to-resident abuse involving the same individuals, and the required care plan interventions were not followed at the time of the observed incidents.
Failure to Provide Required Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide required written notifications regarding transfer, discharge, and bed hold policies for two residents who were transferred to the hospital. For one resident, the medical record indicated a hospital transfer, but there was no documentation that a written notification of discharge or an explanation of the bed hold policy was sent to the resident or their responsible party. Despite requests to the DON for documentation related to all hospitalizations in the past six months, only a written notification for a previous transfer was provided, and no evidence was presented for the transfer in question. The facility's policy referenced notifying the campus manager and maintaining a bed hold authorization or decline form, but did not address the requirement for written notification of transfer or reference the ombudsman log. For the second resident, interview and record review confirmed a hospital transfer, but the resident was not listed on the facility's ombudsman transfer notification log for the relevant month. This indicates that the facility did not notify the ombudsman of the resident's transfer as required. The findings are based on interviews, record reviews, and examination of facility policies and logs, which revealed gaps in documentation and notification processes for resident transfers and bed hold policies.
Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise care plan interventions for a resident with Alzheimer's Disease who was not responsible for her own medical and financial decisions. The resident had a history of behavioral issues, including a recent altercation where she grabbed and squeezed another resident's arm after that resident wandered into her room. Despite this incident, there was no documentation showing that the facility updated or revised the resident's care plan interventions in response to the altercation. The existing intervention, which involved placing a stop sign on the resident's door to deter others from entering, was observed to be ineffective, as the resident frequently removed the sign and placed it elsewhere in the unit. Multiple observations confirmed that the stop sign was not consistently in place on the resident's door when she was not in her room, and staff interviews acknowledged the ineffectiveness of this intervention. The facility's care plan policy requires periodic review and revision of care plans, with removal of interventions that are no longer applicable, but there was no evidence that the care plan was updated following the incident or that alternative interventions were implemented to address the resident's behavioral risks.
Failure to Administer Medication per Physician Order and Incomplete Monitoring After Error
Penalty
Summary
A medication administration error occurred when a resident with diagnoses including anemia, depression, diabetes mellitus, nausea, and hypertension was given 3 mg of lorazepam instead of the prescribed 0.5 mg dose. The error was documented in the resident's progress notes and incident report, which indicated that the resident became lethargic and drowsy following the administration. The Assistant Director of Nursing suggested that the nurse may have confused the resident's dose with another resident's order for lorazepam. Review of the Medication Administration Record (MAR) and controlled substance administration record revealed inconsistencies in documentation, with doses not matching between records and improper notation of a wasted dose instead of recording an error. Following the medication error, physician orders were written to monitor the resident's vital signs twice daily for three days. However, review of the vital sign records showed that no vital signs were recorded for the evening shifts on three consecutive days after the incident. Additionally, there were no nursing progress notes documenting follow-up on the medication error during this period. Interviews with facility leadership confirmed that medication administration protocols and documentation expectations were not followed, and that appropriate disciplinary action and education for the involved nurse had not been confirmed.
Failure to Provide Adequate Supervision During ADL Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident was not properly supervised during Activities of Daily Living (ADL) care, resulting in a fall with injury. The resident, who was known to be impulsive and had cognitive impairment, was being assisted by a CNA for morning dressing. The CNA turned her back momentarily while the resident was seated at the edge of the bed, during which time the resident fell forward and struck her head on the floor. The incident resulted in a large hematoma to the left forehead, ecchymosis to the left eye, a skin tear to the right elbow, and an abrasion to the left knee. The resident was later observed with significant bruising and was unable to respond appropriately during an interview. Staff interviews confirmed that the CNA was kneeling by the resident's feet, attempting to put on pants, when the fall occurred. After the fall, the CNA moved the resident before notifying the RN, which was not in accordance with facility protocol. The DON and the resident's DPOA both acknowledged the resident's impulsive behavior and cognitive deficits, with the DON stating that staff should be aware of these tendencies. The lack of adequate supervision and failure to follow post-fall procedures contributed to the resident's injuries.
Failure to Maintain Sanitary Storage and Cleaning of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage and cleaning of respiratory equipment for two residents who required respiratory services. For one resident with COPD, asthma, and chronic respiratory failure, oxygen tubing was repeatedly observed coiled on the floor next to the bed without a storage bag, with the nasal prongs in direct contact with debris on the floor. The resident confirmed the absence of a storage bag for the tubing. Physician orders indicated the need for continuous oxygen therapy at night and as needed. For another resident with acute respiratory failure, pneumonitis, asthma, and obstructive sleep apnea, a nebulizer with visible condensation in the medication cup was observed left on the bedside table, and a CPAP mask was found in direct contact with a chair. Two sets of oxygen tubing were also seen connected to equipment at the end of the bed without protective covering. Facility staff interviews confirmed that oxygen tubing and CPAP masks should be stored in bags when not in use, and nebulizers should be cleaned and allowed to dry after each use. Facility policies also required proper cleaning and storage of respiratory equipment, which was not followed in these cases.
Failure to Identify and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma triggers for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). Upon admission, the resident's initial trauma screening confirmed a history of trauma and ongoing symptoms, but did not document specific trauma triggers. The psychiatric follow-up report referenced a significant history of psychiatric trauma from an abusive relationship but did not include details about potential triggers. Additionally, when the resident was re-admitted after a hospitalization, the trauma screening section of the nursing assessment was left blank, and no further assessment for trauma triggers was completed. The care plan for the resident did not include any interventions or instructions related to trauma-informed care or PTSD, leaving staff without guidance on how to identify or mitigate trauma triggers. Interviews with the nurse manager and social worker revealed that neither was aware of the resident's specific trauma triggers, and both acknowledged that an assessment and care plan should have been completed. The facility's policy requires screening for trauma history and the development of a care plan to address potential triggers, but this was not followed in the resident's case.
Failure to Ensure Timely Availability of Prescribed Pain Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure the availability of prescribed pain medication for a resident admitted for rehabilitation following multiple fractures sustained in a motor vehicle accident. The resident had orders for both extended-release and immediate-release morphine for pain management. Over a weekend, the resident's supply of morphine ran out, and no refills were available. The medication was not reordered in advance, and there was no in-house provider available to write a new prescription during the weekend. When the resident requested pain medication, the LPN discovered that the medication was depleted and that the back-up medication room did not have additional morphine. Attempts to substitute with oxycodone were unsuccessful due to insufficient supply. The telehealth physician recommended sending the resident to the emergency department (ED) for pain management, as the facility could not provide the necessary medication. The resident experienced significant pain and discomfort during this period, as well as frustration and agitation, as documented in behavior notes. Interviews with facility staff, including the LPN, ADON, and DON, confirmed that the medication should have been reordered before running out and that the pharmacy should have been contacted for refills or a new prescription. Facility policy required nurses to request refills 2-3 days before depletion and to use emergency pharmacy services if needed. The failure to follow these procedures resulted in the resident being sent to the ED for pain control due to the unavailability of prescribed medication.
Failure to Ensure Physician Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) conducted by the pharmacist were addressed by the attending physician and properly documented in the clinical records for two residents. For one resident, the pharmacist made multiple requests for clarification of a diclofenac order and recommended a Gradual Dose Reduction (GDR) for quetiapine, but there was no documentation of physician response or rationale for declining these recommendations in the electronic medical record (EMR). The orders remained unamended, and the physician's section of the MRR forms was left blank. For another resident, the pharmacist recommended obtaining a lipid panel and A1c due to daily use of rosuvastatin and quetiapine, but there was no evidence in the EMR or laboratory results that these tests were performed, nor was there documentation of the physician's reasoning for not following the recommendation. The Director of Nursing confirmed that the facility did not have a system in place to ensure physician responses to pharmacist recommendations were documented, and the facility's policy required providers to review and address all pharmacist recommendations.
Failure to Provide Required Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment, specifically non-slip dycem, to two residents who required it for safe and independent eating, as indicated on their care plans and meal tray cards. Observations during breakfast meals revealed that both residents did not receive the dycem, although one did receive other adaptive utensils. Staff interviews indicated that one resident was no longer using dycem due to a change in feeding assistance needs, but the tray card had not been updated to reflect this change. The registered dietitian confirmed that she had not been informed of the updated equipment needs by the occupational therapy department, resulting in outdated tray card instructions. Medical record reviews for both residents showed documented needs for adaptive dining ware, including dycem, due to conditions such as cerebral palsy, visual impairment, osteoarthritis, dysphagia, dementia, and recent significant weight loss. The facility's policy required dietary staff to provide adaptive equipment as determined by the occupational therapist and to ensure it was placed on the resident's tray at each meal. Despite these documented needs and policies, the required adaptive equipment was not consistently provided, leading to increased difficulty with food consumption and independent eating for the affected residents.
Failure to Administer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
A deficiency was identified when an eligible resident was not provided a pneumococcal vaccine as recommended by the CDC. The resident was admitted for rehabilitation with multiple diagnoses, including fractured ribs, anemia, coronary artery disease, diabetes mellitus, and hypertension. Upon review of the resident's electronic medical record and the Michigan Care Improvement Registry, it was found that the last pneumococcal vaccine was administered several years prior, and the resident was overdue for the recommended vaccination. The admission consent checklist indicated that the resident had consented to receive the pneumococcal vaccine if due. Despite the facility's policy and the Director of Nursing's statement that all new admissions who consent to vaccination should receive it within the first week and no later than 14 days after admission, the resident had not received the pneumococcal vaccine during their stay. The facility's policy outlined the procedures for offering and administering the vaccine based on current vaccination status and practitioner recommendation, but these procedures were not followed in this case.
Failure to Administer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to ensure that eligible residents were provided with the COVID-19 vaccine as recommended by the Centers for Disease Control and Prevention (CDC). Two residents admitted for rehabilitation, both with significant medical histories including conditions such as fractured ribs, anemia, coronary artery disease, diabetes mellitus, acute respiratory failure, atrial fibrillation, heart failure, pneumonia, and hypertension, were identified as overdue for the COVID-19 vaccine according to the Michigan Care Improvement Registry (MICR). Despite documentation on their admission consent checklists indicating consent to receive the COVID-19 vaccine if due, neither resident received the vaccine during their stay. Review of the electronic medical records (EMR) for both residents confirmed that no COVID-19 vaccine had been administered since their initial admissions. The Director of Nursing (DON) stated that the facility maintains vaccines on hand and expects all new admissions who consent to vaccination to receive it within the first week, and no later than 14 days after admission. However, this protocol was not followed for the two residents in question, as evidenced by the lack of vaccine administration documented in their records.
Failure to Assess and Manage Bowel Function Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adequately assess and manage the bowel function of a resident who was admitted for rehabilitation following knee replacement surgery. The resident, who had a history of cerebrovascular accident with right-sided hemiplegia and was on opioid medication, began complaining of abdominal pain and constipation shortly after admission. Despite these complaints, the facility did not conduct a thorough bowel assessment or follow their bowel management protocol, which led to the resident experiencing severe constipation and subsequent hospitalization. The resident's medical records indicated sporadic documentation of bowel movements and assessments, with only two documented bowel assessments during the resident's stay. Interviews with nursing staff revealed a lack of awareness and recall regarding the resident's complaints and the necessary assessments. The Director of Nursing confirmed that a thorough nursing assessment should have been conducted when the resident first complained of constipation, especially given the resident's opioid use post-surgery. The facility's bowel program policy outlined specific procedures for monitoring and managing bowel function, including interventions if no bowel movement occurred within a specified timeframe. However, these procedures were not followed, resulting in the resident's condition worsening to the point of hospitalization. The resident ultimately passed away, with the death certificate citing ischemic colitis, septic shock, and organ failure as causes of death.
Failure to Protect Residents from Verbal Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect by a staff member, specifically involving three residents. Resident #1, who had severe cognitive impairment and was dependent on assistance for toileting hygiene, reported that a CNA threw a brief on the bed and left without assisting him. Resident #1 expressed dissatisfaction with the CNA's attitude, describing it as rude. Resident #2, with moderate cognitive impairment, required moderate assistance for toileting hygiene. She reported that her call light fell during the night, and when she resorted to banging on her bedside table for help, the CNA assisted her to the restroom but did not provide thorough peri-care. Despite her request for additional cleaning, the CNA told her to speak to her nurse in the morning and left the room. Resident #3, who had intact cognition and was dependent on assistance for dressing, experienced issues with her intravenous pump leaking, resulting in wet bedding. She reported that the CNA swatted her hand away and told her to be quiet, as she was waking others. The CNA was described as rude and condescending, and the resident was left in a wet gown and linens throughout the night. These incidents were corroborated by other staff members who received complaints from the residents the following morning.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide advanced written notice prior to a room change for a resident with severe cognitive impairment. The resident, who was initially admitted with diagnoses including Parkinson's Disease and neurocognitive disorder with Lewy bodies, was moved to a secured memory care unit shortly after admission without prior written notification to the resident or their representative. This action was taken after the resident wandered out of their room twice, and the decision to transfer was directed by the Director of Nursing (DON). The resident's spouse expressed displeasure and confusion regarding the move, indicating that she was not informed about the implications of the transfer to the secured unit. The spouse was only notified by a nurse after the move had occurred, and upon visiting, she felt the placement was inappropriate. The DON confirmed that the usual process of obtaining consent prior to such a move was not followed, and no written notification was provided before the room change.
Resident Subjected to Verbal and Mental Abuse by Facility Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and verbal abuse by facility staff. The incident involved a resident who was admitted with a primary diagnosis of liver cell carcinoma and was independent in mobility and decision-making. The resident was subjected to an intimidating encounter with the former Nursing Home Administrator (NHA), who chastised the resident for going outside into the courtyard unattended. The NHA, appearing visibly upset, pointed a finger in the resident's face and told him he could not go outside until permitted, which left the resident feeling embarrassed and fearful of eviction. Witnesses, including the Assistant Director of Nursing (ADON) and a Registered Nurse (RN), confirmed the NHA's intimidating demeanor during the incident. The resident, who previously enjoyed going outside, did not sign out to the courtyard again after the incident. The facility's investigation substantiated the complaint, and the NHA is no longer employed at the facility. The facility's policy defines verbal and mental abuse, which includes humiliation and threats, aligning with the actions observed during the incident.
Inappropriate Placement in Secured Unit
Penalty
Summary
The facility failed to develop and implement appropriate policies and procedures for the placement of a resident in a secured unit, leading to a deficiency in protecting the resident from involuntary seclusion. The resident, who was admitted with Parkinson's Disease and a neurocognitive disorder with Lewy bodies, was moved to a secured memory care unit shortly after admission without displaying behaviors that warranted such a move. The resident's medical records indicated severe cognitive impairment but did not show any physical or verbal behavioral symptoms, rejection of care, or wandering behavior. Despite this, the Director of Nursing (DON) directed the transfer to the secured unit after the resident was found outside his room twice, which was attributed to confusion and disorientation. Interviews with staff and the resident's spouse revealed that the move to the secured unit was atypical and not based on specific clinical criteria or an emergent need. The Assistant Director of Nursing (ADON) confirmed that the resident's behavior did not pose a safety concern, and the Elopement Evaluation indicated no risk for elopement. The resident's spouse expressed dissatisfaction with the placement, stating it was unexpected and inappropriate. The facility's policy on resident care rights was not adhered to, as there was no documented clinical justification or ongoing assessment for the resident's placement in the secured unit, nor was it determined to be the least restrictive approach.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the appropriate time frame for a resident, resulting in the potential for continued abuse. The incident involved a former Nursing Home Administrator (NHA) who was reported to have verbally and mentally abused a resident by yelling, pointing a finger in the resident's face, and restricting the resident's movement. The Assistant Director of Nursing (ADON) witnessed the incident and reported it to the Director of Nursing (DON) on the same day, providing a written statement. However, the DON did not report the incident to the State Agency, as she did not perceive it as abuse but rather a violation of the resident's rights. The facility's policy requires immediate reporting of any potential or actual abuse to the Administrator and the DON, with a subsequent report to the state survey and certification agency within five working days. Despite this policy, the incident was not reported to the State Agency until several months later, after a complaint was filed with the facility's Human Resources Department. The delay in reporting the incident to the State Agency was a violation of the facility's abuse prevention policy and state law, as the incident was not reported until a complaint was filed, indicating a failure in the facility's internal reporting and response processes.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of verbal abuse involving a resident who was called a derogatory name by a member of the housekeeping staff. The incident was reported by a staff member who witnessed the event, and the resident involved confirmed the occurrence during an interview. Despite the resident being cognitively intact and expressing feelings of being demeaned by the comment, the Director of Nursing (DON) did not ensure a comprehensive investigation was conducted. Witness statements from two CNAs confirmed the incident, but there was no documentation of a formal interview with the resident or any other residents to assess the extent of the issue. The facility's policy on abuse prevention requires a detailed investigation process, including interviews with the resident, witnesses, and other staff, as well as a review of the resident's medical record. However, the DON assumed the resident was not affected by the incident and did not pursue further investigation. The incident was not documented in the resident's medical record, and no post-incident evaluation was conducted to assess the resident's response. This lack of thorough investigation and documentation resulted in a deficiency, as it left the potential for unidentified and continued abuse.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to provide timely notification to the physician for a resident who experienced a change in condition, resulting in a delay in medical treatment and subsequent death. The resident, who had a history of stroke, anemia, and gastro-esophageal reflux disease, was admitted to the facility and had a BIMS score indicating intact cognition. During a midnight shift, a CNA reported to an LPN that the resident was short of breath and had multiple black tarry stools, which are indicative of a potential gastrointestinal bleed. Despite these symptoms, the LPN, who was a newer nurse, did not contact the on-call physician but instead wrote the concerns in a provider book for review at the next provider round. The LPN sought assistance from an RN, who was the Campus Coordinator, but did not provide complete information about the resident's condition, specifically omitting the detail about the black tarry stools. The RN stated that had he been informed of all the symptoms, he would have sought immediate medical evaluation. The facility's policy on change in condition required the use of SBAR to notify the physician and proceed as instructed, which was not followed in this case. The resident's vital signs showed abnormalities, including an elevated respiration rate, but these were not compared to the resident's baseline. Later, another RN found the resident unresponsive with no pulse or breathing and initiated CPR while calling EMS. The resident was pronounced dead after EMS intervention. The Medical Director confirmed that the symptoms presented by the resident, including black tarry stools and hemodynamic symptoms, warranted an immediate call to the on-call provider. The death certificate listed acute end organ failure and gastrointestinal bleed as the cause of death, with the interval between onset and death being hours.
Failure to Provide Timely Laboratory Services for Diabetic Resident
Penalty
Summary
The facility failed to provide timely laboratory services as per physician's orders for a resident with type two diabetes and moderate cognitive impairment. The resident was supposed to have an A1c test every three months to manage diabetes, but the last test was conducted several months prior. The facility's medical director discontinued the resident's diabetes medication without informing the resident's durable power of attorney. This lack of communication and failure to conduct the A1c test as ordered contributed to the resident's extreme elevation of blood glucose levels. The resident exhibited symptoms of lethargy, inability to communicate, and refusal to eat or drink, prompting a nurse to check the resident's blood glucose levels, which were found to be critically high. The resident was sent to the emergency room and diagnosed with severe hyperglycemia and diabetic ketoacidosis. The resident was hospitalized and later returned to the facility, where they passed away while on hospice care. The facility's policy required diagnostic services to be provided per physician's orders, which was not adhered to in this case.
Failure to Inform Resident's Representative of Medication Change
Penalty
Summary
The facility failed to inform a resident's representative about a significant change in medication for a resident with moderate cognitive impairment. The resident, who had been diagnosed with dementia, type two diabetes with hyperglycemia, and a cognitive communication deficit, had their diabetes medication discontinued by the facility's medical director. Despite the resident's Durable Power of Attorney (DPOA) having the authority to make medical treatment decisions, they were not informed of this change at the time it was made. The facility's policy requires that residents and their legal representatives be informed of significant changes in treatment. However, the review of the resident's electronic medical record did not show any communication with the DPOA regarding the stoppage of Metformin. The Director of Nursing confirmed that the DPOA was not notified prior to the medication change, which was against the facility's standard practice of clarifying with the DPOA before making such changes.
Failure to Notify Physician and Administer Treatment Timely
Penalty
Summary
The facility failed to ensure appropriate and timely assessments and physician/provider notification for a change in condition for Resident #173, who was admitted with multiple diagnoses including congestive heart failure and atrial fibrillation. The resident became hypotensive and unresponsive, ultimately expiring in the facility. Despite low blood pressure readings, there were no documented physical assessments or physician notifications, and scheduled medications were withheld without proper authorization. The Director of Nursing confirmed that the low blood pressure readings and withholding of medications warranted physician notification and should have been considered a change in condition. In another case, the facility failed to adhere to physician treatment orders for rehabilitation services and fluid administration for Resident #621, who was admitted with dementia and a fracture of the left femur. The resident exhibited symptoms of respiratory illness and sepsis, but there was a significant delay in administering ordered IV fluids. The Licensed Practical Nurse on duty received orders for IV fluids but was instructed to delay administration until the night shift, resulting in a delay of several hours. The Assistant Director of Nursing confirmed that the delay in treatment was unacceptable. Both deficiencies resulted in severe consequences for the residents involved, with Resident #173 experiencing actual harm and Resident #621 suffering from delayed treatment, hospitalization, sepsis, and death. The facility's failure to follow proper procedures for assessing changes in condition and adhering to physician orders contributed to these outcomes.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Kitchen staff were seen removing soiled trays, utensils, and uneaten food from transport carts without cleaning the carts afterward. These carts were then moved to an adjacent dining area without being sanitized. A food service worker was observed attempting to clean the carts by dabbing a small portion of the interior surfaces with disinfectant, covering less than 2% of the surface area. The kitchen manager acknowledged that this cleaning process was inappropriate and stated that the carts would be properly sanitized before being used again. Additionally, a food service worker was observed washing his hands and then using his bare hands to push down on a trash container lid before returning to the serving line. This action violated the FDA Food Code, which requires food employees to wash their hands immediately before engaging in food preparation or handling clean equipment and utensils. These deficiencies in food handling and sanitation practices have the potential to result in foodborne illness among the facility's residents.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program, which is crucial for the development, monitoring, and evaluation of adverse events to correct quality deficiencies. This deficiency had the potential to affect all 164 residents in the facility. During an interview, the Registered Nurse (RN)/Staff Educator responsible for overseeing the QAPI process confirmed that adverse events, such as unexpected deaths, were discussed in Interdisciplinary Team (IDT) meetings but not within the QAPI framework. The RN/Staff Educator acknowledged considering an unexpected death as an adverse event but admitted it was not discussed in QAPI meetings. Furthermore, the RN/Staff Educator was unable to explain how medical errors or adverse resident events were identified, analyzed, corrected, or monitored to ensure desired outcomes through the QAPI process. The facility's policy, titled Quality Assurance Performance Improvement Plan, indicated that the facility has a Performance Improvement Program designed to systematically monitor, analyze, and improve its performance to enhance resident outcomes. The policy stated that adverse events and daily IDT notes, including adverse events and complaints, are reviewed daily, with a mechanism for communicating patterns and trends identified during IDT meetings to the broader QAPI Committee. However, the facility did not adhere to this policy, as adverse events were not effectively integrated into the QAPI process.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for their transfers to the hospital. This deficiency was identified for four residents during a review of facility-initiated transfers. Resident #56 was transferred to the hospital without any written notification being provided to them or their representative, as confirmed by the Electronic Medical Record (EMR) and interviews with the Director of Nursing (DON) and the Social Worker. Similarly, Resident #1 was transferred to the hospital without written notification, as confirmed by the medical record and staff interviews. Resident #621 was also transferred to the hospital without receiving written notification, as verified by the facility's census report and interviews with the DON and staff. Additionally, Resident #149 was hospitalized without a written notification of transfer, as confirmed by the EMR and the Assistant Director of Nursing (ADON). The facility's policies on discharge and transfer procedures, as well as resident care policies, were reviewed and found to require written notification, which was not adhered to in these cases.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents or their representatives during hospital transfers. Resident #621 was transferred to an acute care hospital for evaluation, as noted in the electronic medical record (EMR) on 7/11/24. However, interviews with the Director of Nursing and a Social Worker confirmed that no bed hold policy was issued to Resident #621 upon transfer. Similarly, Resident #149 was hospitalized from 6/19/24 to 6/30/24, and the EMR did not indicate that a bed hold policy was provided. An interview with the Assistant Director of Nursing verified that Resident #149 did not receive a bed hold policy upon transfer. The facility's policy requires contacting the responsible party to inform them of the right to hold a bed and activating a Bed Hold Form, which was not followed in these cases.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed psychotropic medications. The resident, who had diagnoses including dementia with psychotic disturbance, depression, and anxiety disorder, was admitted to the facility with severely impaired cognition. The care plan for this resident included the use of psychotropic medications for end-of-life comfort measures but lacked specific targeted behaviors, indications of use, or person-centered, non-pharmacological interventions to be used prior to administering the medication. During an interview, the Assistant Director of Nursing confirmed that the care plan did not include necessary focus areas such as triggers for behavior or non-pharmacological interventions related to the use of as-needed anti-anxiety medication. The facility's policy on care planning requires a comprehensive care plan to meet each resident's clinical and psychosocial needs, including documenting the resident's problems, needs, goals, objectives, and interventions. The absence of these elements in the care plan for the resident resulted in the potential for unnecessary use of mood-altering drugs and decreased quality of life.
Failure to Apply Orthopedic Braces as Ordered
Penalty
Summary
The facility failed to apply orthopedic braces per physician orders for two residents, resulting in a potential reduction in range of motion and complications following surgery. Resident #155, who was admitted with diagnoses including surgical aftercare following spinal surgery and quadriplegia, was observed multiple times without the prescribed cervical collar. Despite having a care plan and physician orders indicating the collar should be worn at all times, staff members were either unaware of the order or incorrectly believed the resident could remove it while in bed. Interviews with staff, including CNAs and the Assistant Director of Nursing, revealed a lack of awareness and understanding of the resident's needs and the importance of the cervical collar in protecting the surgical site. Resident #104 was observed without the ordered lamb's wool palm shield/protectors, which were intended for contracture management. The resident's hands were noted to be contracted with overlapping fingers, and staff members were unsure of the wearing schedule for the orthotic devices. Interviews with CNAs and an LPN revealed confusion about the resident's care plan, with some staff unaware that the palm protectors should be worn during the day. The EMR for Resident #104 did not contain a physician order for the palm protectors, but a therapy communication note recommended their use during specific times of the day and night. The facility's policies on resident braces, orthotics, and assistive devices require written orders and care plans for wearing frequency, as well as documentation of refusals and poor-fitting devices. However, the observations and interviews indicated a failure to adhere to these policies, leading to the deficiencies noted in the care of Residents #155 and #104. The lack of proper application and monitoring of prescribed orthotic devices highlights a gap in staff education and communication regarding resident care plans.
Failure to Prevent Unsafe Wandering and Elopement
Penalty
Summary
The facility failed to implement appropriate interventions to prevent unsafe wandering and elopement for three residents, resulting in continued unsafe supervision and an elopement from the locked memory care unit. Resident R132, diagnosed with dementia and severe cognitive impairment, was noted to be at risk for elopement. On one occasion, R132 eloped from the unit after being mistaken for a visitor by a dietary aide, and there was no incident report filed for this event. The care plan for R132 included monitoring and documenting wandering behavior, but these interventions were not effectively implemented. Resident R156, also diagnosed with dementia and severe cognitive impairment, exhibited wandering behavior and attempted to elope by triggering a fire exit alarm. Despite the care plan interventions to distract and provide structured activities, staff were unable to effectively redirect R156, who was observed wandering into other residents' rooms and attempting to leave the facility. The staff's inability to supervise and redirect R156 highlights a deficiency in the facility's supervision and intervention strategies. Resident R221, with Alzheimer's disease and severe cognitive impairment, was observed wandering and entering other residents' rooms without staff intervention. R221's care plan included interventions to distract and provide structured activities, but these were not effectively implemented. The Assistant Director of Nursing acknowledged the difficulty in supervising all residents, and the Director of Nursing confirmed that residents should not be allowed to wander into other residents' rooms, indicating a staffing issue in the memory care unit.
Failure to Provide Consistent Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen services per standards of practice for a resident, resulting in a potential risk for hypoxia and respiratory complications. The resident, who was admitted with diagnoses including pneumonia, shortness of breath, and sleep apnea, was observed multiple times without supplemental oxygen applied, despite having active physician orders for continuous oxygen at 2 liters via nasal cannula. The resident expressed confusion about her oxygen therapy, indicating a lack of clarity in her care plan. The deficiency was further compounded by contradictory physician orders to both provide continuous oxygen and to wean oxygen as able, without specific parameters for acceptable oxygen saturation levels. This lack of clear guidance led to inconsistent application of oxygen therapy, as evidenced by the resident's oxygen saturation dropping to 88% before supplemental oxygen was reapplied. Interviews with nursing staff and administration confirmed the confusion and acknowledged the need for defined oxygen saturation parameters in the orders.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were properly addressed by the physician and documented in the clinical records for two residents. For Resident #61, the pharmacist recommended a gradual dose reduction (GDR) of antianxiety medications and a reduction in melatonin dosage. However, the physician did not provide a written response to these recommendations, leaving the report sections blank, unsigned, and undated. The Director of Nursing (DON) confirmed the lack of documented physician follow-up and could not verify if the physician had received the pharmacist's recommendations. For Resident #91, the pharmacist recommended conducting an Abnormal Involuntary Movement Scale (AIMS) assessment, but the facility failed to complete this assessment in a timely manner. The DON acknowledged that AIMS assessments were not conducted following the pharmacist's recommendations in April and May, with the next assessment only occurring in July. The facility's policy required the DON to share pharmacist recommendations with the physician and ensure they were addressed, but this process was not followed, leading to the deficiency.
Failure to Document and Use Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure proper documentation and use of non-pharmacological interventions before administering as-needed anti-anxiety medication to a resident. The resident, who was admitted with diagnoses including dementia with psychotic disturbance, depression, and anxiety disorder, had severely impaired cognition. The Medication Administration Records (MARs) from June to September 2024 showed multiple administrations of lorazepam without documented reasons for its use or any recorded behaviors or symptoms that warranted the medication. Additionally, there was no evidence of non-pharmacological interventions being attempted prior to the administration of the medication. During an interview, the Assistant Director of Nursing (ADON) confirmed that targeted behaviors and indications for the use of as-needed psychotropic medications should be documented, and non-pharmacological interventions should be attempted first. The facility's policy on psychoactive medication use also mandates that non-pharmacological interventions be tried and proven ineffective before administering as-needed medications. However, the review of the resident's electronic medical records revealed a lack of documentation for the targeted behaviors or the use of non-pharmacological interventions on the specified dates.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for three residents, leading to a deficiency in dental care. Resident #49 reported breaking a tooth a month prior and expressed uncertainty about when she would see a dentist. Despite having a history of dental issues and a desire to consent to in-house dental services, there was confusion regarding her consent status, as her son had signed a consent form. The social worker confirmed that Resident #49 was on a list to be seen by the contracted dental provider, but no specific appointment date was known, and no follow-up for an outside appointment was documented. Resident #61 experienced significant tooth pain and had been waiting over two weeks to see a dentist. His family member confirmed that they had inquired about the dental visit but received no information on when the dentist would be available. The Assistant Director of Nursing (ADON) admitted to not knowing the frequency of dental visits or the date of the last visit. A dental clinic list was eventually provided, showing a tentative date for the next visit, but it was unclear if this would address Resident #61's immediate needs. Resident #56 had lost significant weight due to ill-fitting dentures and was unable to eat properly. Despite being aware of the issue since July, the facility had not arranged for a dental appointment. The Assistant Director of Nursing stated that there had been issues with consents and that social services had been working on the necessary paperwork, but a change in personnel led to a lack of follow-up. The resident's care plan highlighted the risk of further weight loss and nutritional issues, yet no timely dental intervention was provided.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to evaluate and treat a resident for therapy services, leading to discomfort for the resident when seated in her wheelchair. On observation, the resident was seen in a high back wheelchair with her legs elevated and feet pushed against the foot cradle, expressing discomfort due to the chair being too long. A progress note in the Electronic Medical Record (EMR) recommended an occupational therapy (OT) evaluation and treatment to address positioning, and a physician order was written for OT to evaluate and treat if indicated. However, during an interview, a physical therapist acknowledged that the OT screen and evaluation were not conducted, and the Director of Nursing stated that she would expect nursing staff to follow up on physician orders.
Lack of Communication and Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure effective collaboration and communication between the facility and the hospice provider for a resident receiving hospice services. The resident, who was admitted with Alzheimer's disease, dementia with behavioral disturbance, and dysphagia, was unable to complete the Brief Interview for Mental Status (BIMS) and had severely impaired cognition. The resident's Designated Power of Attorney (DPOA) expressed concerns about the lack of communication between the hospice services and the facility, indicating uncertainty about the care being provided. Upon review, it was found that the hospice notes documented only two visits in August 2024, despite the hospice care agreement requiring regular documentation and coordination of care. The Assistant Director of Nursing (ADON) confirmed the limited documentation, and the Director of Nursing (DON) verified the absence of additional hospice documentation since August 23, 2024. The facility's hospice care agreement outlined the need for coordination and documentation of hospice visits, which was not adhered to, resulting in gaps in communication and coordination of care for the resident.
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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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