Harmony Village Of Clawson
Inspection history, citations, penalties and survey trends for this long-term care facility in Clawson, Michigan.
- Location
- 535 N Main, Clawson, Michigan 48017
- CMS Provider Number
- 235214
- Inspections on file
- 33
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Harmony Village Of Clawson during CMS and state inspections, most recent first.
Two legally incapacitated residents with severe cognitive impairment were found unsupervised and involved in a sexual encounter, both unclothed from the waist down. Despite documented histories of impaired judgment, behavioral disturbances, and legal guardianship, staff failed to provide adequate supervision or intervention. The residents were unable to recall the incident or understand the risks, and staff and guardians confirmed the lack of capacity for consent. The facility permitted the encounter despite clear evidence of incapacity and vulnerability.
A resident with dementia who required extensive assistance for all ADLs suffered a preventable fall and femur fracture when a CNA, misunderstanding care requirements, provided incontinence care alone instead of with two staff as documented in the care plan and Kardex. Contradictory interventions and lack of clear guidance from the interdisciplinary team contributed to the incident, resulting in injury and pain for the resident.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A CNA worked in the facility with a lapsed certification, as confirmed by personnel and timecard records. The lapse was only discovered when the survey team requested the CNA's file, and the Administrator acknowledged the issue after being informed by HR. No further explanation or documentation was provided.
A nurse failed to administer medications to 11 residents during an evening shift, leading to a neglectful incident. The residents, including those with dementia and myocardial infarction, missed critical medications. The nurse was on the phone with the pharmacy and did not pass medications, resulting in termination due to negligence. The facility's investigation found inconsistencies in EMAR documentation.
A nurse failed to administer medications to several residents during an extended shift, leading to a neglect incident that was not reported to the State Agency. The DON discovered inconsistencies in the EMAR documentation, and the nurse was terminated. The acting Administrator later identified the incident as neglectful, but it was not reported as required by the facility's policy.
A facility failed to assess a resident for safe self-administration of medication. The resident, with intact cognition and multiple diagnoses, was found self-administering a breathing treatment without an assessment, care plan, or physician order. The facility's policy requires these steps, but they were not followed, as confirmed by staff interviews.
A resident with high cognitive function and mobility challenges expressed a preference for showers over bed baths, but was unable to take showers due to their wheelchair not fitting into the shower room. Despite the resident's clear preference, the facility had not yet found a solution to accommodate this need.
A facility failed to ensure an annual review of a DNR order with a legal guardian for a resident with impaired cognition and mental health diagnoses. The facility did not document communication between the guardian and physician regarding the DNR status, as required by state law. The social worker was unaware of the annual review requirement, and the facility's policy did not address this need.
Two residents' privacy was compromised when a privacy curtain between their beds was removed for cleaning and not promptly replaced. Staff interviews revealed a lack of awareness about the availability of extra curtains, leading to a prolonged absence of the curtain. The Regional Director of Operations later confirmed that extra curtains were available, indicating a communication breakdown within the facility.
A facility failed to maintain a clean and homelike environment for a resident with severe cognitive impairment. The resident was observed with a pile of hair under their bed, which remained even after their transfer to a hospital. Despite the facility's policy requiring routine cleaning, the housekeeping supervisor confirmed that the area under the bed was not cleaned as expected. The CNAs involved denied cutting the resident's hair, and the facility's policy on maintaining a sanitary environment was not followed.
A resident with severe cognitive impairment was discharged from the hospital with instructions to receive Ciprofloxacin, but the medication was not transcribed into the facility's records. The facility's ICP noticed the omission but had not contacted the physician. The DON confirmed that hospital orders should be transcribed accurately, and any changes should be documented.
A facility failed to submit a Change in Condition form for a resident with a new schizophrenia diagnosis, as required for a level two OBRA evaluation. The resident was readmitted with schizophrenia, but the necessary form was not completed until identified during a survey. The Social Services Manager acknowledged the oversight, which was contrary to the facility's policy requiring prompt referral for a level II resident review.
A facility failed to complete a PASARR Level II evaluation for a resident with schizoaffective disorder after the 30-day hospital exemption period. The resident's record inaccurately indicated a Level II had been issued, and the Social Services Manager only submitted the evaluation after the surveyor's review. Facility policy requires a Level I screening and, if necessary, a Level II evaluation within 40 days if a resident stays beyond the exemption period.
A facility failed to meet professional standards in diagnostic practices for a resident diagnosed with schizophrenia. The resident, previously diagnosed with Parkinson's disease, was prescribed Seroquel without documented clinical rationale or DSM-5 criteria. Staff interviews revealed a lack of awareness and follow-up on the diagnosis, and the facility could not provide a policy on professional standards for diagnostic practices.
A resident with a history of heart failure and dysphagia, identified as at moderate risk for skin breakdown, did not receive timely and effective pressure ulcer care. The resident was observed without necessary offloading devices and reported pain from a bed sore, with staff failing to apply prescribed zinc barrier ointment. Observations showed multiple open sores on the resident's coccyx area without treatment, and wound care orders were not properly transcribed, leading to inadequate care.
The facility failed to ensure a hazard-free environment for two residents. One resident was observed using oxygen therapy with petroleum jelly nearby, posing a fire risk. Another resident's room contained hazardous cleaning chemicals accessible to them. Staff did not identify or address these hazards, contrary to facility policy.
A facility failed to provide necessary social services to a resident with multiple mental health diagnoses, including schizophrenia. The resident's guardianship documentation had expired, and the social services manager was unaware of the new diagnosis and did not ensure follow-up on mental health needs. The facility's policy required advocating for residents and ensuring legal representation, but the social services manager failed to identify the expired guardianship and address the resident's mental health needs.
A facility failed to document specific irregularities identified by a consultant pharmacist during monthly medication regimen reviews for a resident with multiple diagnoses, including dementia and mood disorders. The facility's policy requires written communication of such irregularities and physician responses, but these were not available in the resident's medical record. Despite requests, the facility did not provide the necessary documentation by the end of the survey.
The facility failed to securely store and properly label medications for two residents. A prescribed ointment was found unsecured on a bedside table in one resident's room but labeled for another resident. Despite being observed on different days, the ointment remained unsecured until a nurse was informed and removed it. This violated the facility's policy requiring medications to be stored securely and only accessible to authorized personnel.
The facility failed to complete physician-ordered lab tests for a resident with multiple diagnoses, including subdural hemorrhage and dementia. The lab tests, ordered due to conditions such as hypertension and seizures, were not processed because the requisition was never made. This oversight occurred during a transition to a new medical provider, leading to the nurses missing the lab order.
A resident with congestive heart failure and COPD experienced discrepancies in wound care documentation, leading to potential misidentification and inappropriate treatment. Medical Provider W initially ordered hydrogel with Xeroform, but later changed to Xeroform only. However, evaluations on later dates incorrectly included hydrogel, which was acknowledged as an error by the provider.
The facility failed to provide appropriate Medicare and Medicaid coverage notices to three residents, resulting in them being uninformed about potential private pay charges and their inability to file an appeal. Documentation showed missing or outdated forms, and staff interviews revealed confusion and recent changes in the process of completing these forms.
The facility failed to provide sufficient staffing for 43 residents on the second floor, particularly during the midnight shift, resulting in potential unmet care needs. Staffing was based on budget rather than acuity, leading to shifts with fewer than the required CNAs. On one occasion, two nurses had to perform both nursing and CNA duties for 43 residents with high acuity needs. Interviews revealed that residents were not adequately cared for, with reports of neglect due to insufficient staffing. The facility lacked a policy on sufficient staffing and did not document specific staffing needs.
A facility failed to follow its grievance policy when a resident, who required a Geri chair for transport, was unable to visit family on Christmas due to transportation issues. The family was not informed in a timely manner and their subsequent calls to the social worker were not returned. The facility did not document or address the grievance, and the administrator was unaware of the issue.
The facility failed to protect residents from abuse, with incidents involving residents with cognitive impairments and behavioral issues. A resident with severe cognitive impairment was involved in altercations, including being slapped and pushed by other residents. Inadequate supervision and inconsistent staffing contributed to these incidents. Another resident with a history of aggressive behavior hit a severely impaired resident with a shoe, highlighting the facility's failure to assess and plan for behavioral needs.
The facility inadequately investigated an allegation of resident-to-resident physical abuse. A resident reported being hit by another resident, but the investigation was limited to interviewing only one LPN and did not include other potential witnesses or affected residents. The facility's policy requires a comprehensive investigation, which was not conducted, leading to the deficiency.
A resident with severe cognitive impairment, blindness, and hearing loss sustained a skin tear due to the facility's failure to implement care planned interventions for bed mobility and toileting, and to address combative behaviors. The resident, known to be combative during ADL care, was handled by a CNA who did not follow the care plan requiring two-person assistance. The care plan was not updated to address the resident's hearing deficit until after the incident.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and alarm systems. The resident exited through the front door, which had a low-volume alarm, and was found near a bus stop by an RN. The facility's investigation lacked witness statements and a root cause analysis, and staff interviews revealed insufficient monitoring of doors after hours. The resident's care plan did not reflect their elopement risk, and the facility's policy on elopement was not effectively implemented.
A resident with dementia and spastic hemiplegia suffered a right medial malleolus fracture due to the facility's failure to implement care plan interventions. The resident's wheelchair lacked foot pedals, and a required Prafo boot was not applied, leading to the injury. Staff were not adequately educated on the use of resident devices, contributing to the deficiency.
The facility failed to report a black eye of unknown source for a resident and inaccurately reported an ankle fracture for another resident to the State Agency. A resident with severe cognitive impairment was observed with a fresh bruise under their left eye, which was not reported within the required timeframe. Another resident with severe cognitive impairment and a history of dementia was found to have a bruise on their right ankle, but the facility failed to report the fracture identified by the hospital. The Administrator delayed reporting and claimed unawareness of the fracture, despite documentation indicating its presence.
A resident with serious medical conditions was transferred from a facility without proper documentation or physician orders. The facility failed to provide a discharge summary or arrange transportation, resulting in the resident being transferred in a family car. Staff interviews revealed a lack of awareness and documentation regarding the transfer.
A resident admitted with acute respiratory failure and other serious conditions did not receive a physician-ordered medication due to a failure in the facility's medication management process. The medication was not ordered on the day of admission, and despite nurses signing off on its administration, it was confirmed that the medication was never delivered.
A resident with a history of aggressive behavior pushed another resident, causing a head injury and hospital transfer. Both residents had dementia, and the facility's investigation did not substantiate abuse, despite confirming the incident. The facility's policy defines abuse as willful infliction of injury, but the administrator believed dementia negated the abuse classification.
A resident with dementia and violent behavior was found with facial injuries, initially documented as an unwitnessed fall. The facility failed to report the incident as an injury of unknown origin to the Administrator and State Agency. The Administrator and DON relied on incomplete information, and the facility's policy on immediate reporting was not followed.
A resident with dementia and violent behavior was found with injuries, including two black eyes and a forehead bruise, but the LTC facility failed to thoroughly investigate the cause. The incident was categorized as a fall, despite no witnesses and the resident being found in a bed. The facility's policy required an immediate investigation for injuries of unknown origin, which was not conducted, leading to a deficiency in addressing potential abuse or neglect.
A resident with severe cognitive and physical impairments was not provided with ongoing individual activities, as required by the facility's policy. The resident was observed alone multiple times without engagement, and the Recreation Director cited staffing challenges as a barrier to providing daily activities. The NHA and DON acknowledged the deficiency and mentioned plans for a new activities program.
The facility failed to ensure an environment free from sexual abuse for two cognitively impaired residents who lacked the ability to consent to physical intimacy. One resident wandered into another's room, and both were found undressed in bed together. Immediate actions were taken to separate the residents and place them under supervision, but the incident highlights a deficiency in ensuring a safe environment for residents.
The facility failed to submit an abuse investigation within the mandatory five business day time-frame for two residents. One resident was found without clothes in another resident's room, who was also without clothes. The incident was reported, and an investigation was initiated immediately. However, the investigation was not submitted to the State Agency until beyond the required time frame due to access issues and unavailability of the new Administrator.
The facility failed to protect a vulnerable resident with severe dementia from a sexual incident initiated by another cognitively intact resident. The staff did not notify law enforcement immediately, failed to preserve evidence, and did not conduct a thorough investigation. The administrator did not provide clear directives for monitoring the perpetrator, leaving other vulnerable residents at risk.
The facility failed to prevent an incident of resident-to-resident sexual abuse involving two residents, one with severe cognitive impairment and the other with intact cognition. The incident was inadequately handled, with the vulnerable resident left alone with the perpetrator and potential evidence washed before police examination.
The facility failed to report an allegation of sexual abuse within the required timeframe, resulting in delayed notification to law enforcement and the State Agency. Staff did not preserve evidence, and the Administrator did not provide clear directives, compromising the investigation.
Failure to Prevent Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to appropriately assess, supervise, and ensure an environment free of sexual abuse for two legally incapacitated residents with severely impaired cognition. Both residents, one with a BIMS score of 2 and the other with a BIMS score of 3, were found unsupervised and involved in a sexual encounter in one resident's bed, both unclothed from the waist down. Staff discovered the incident during the night shift, and it was noted that one resident had a history of seeking male attention and inviting male residents into her room, while the other had a history of sexually inappropriate behavior and aggression. Medical records and care plans for both residents documented severe cognitive impairment, legal guardianship, and the need for supervision and redirection due to behavioral symptoms and impaired judgment. Despite these documented vulnerabilities, the facility permitted the residents to engage in sexual activity without adequate supervision or intervention. Staff, including the Administrator and Nurse, acknowledged that the resident involved was unable to recall the incident, understand the risks or consequences of sexual encounters, or provide meaningful consent due to her dementia and cognitive deficits. Interviews with the social worker, legal guardian, and staff confirmed that the resident could not process or remember the events and did not have the capacity to understand or consent to sexual activity. The facility's own policy required both decision-making capacity and capacity for sexual consent evaluations, yet the resident had previously been declared mentally incapacitated and unable to make informed decisions. Despite this, a physician's assessment after the incident concluded that the resident had capacity to consent, a determination that was questioned by staff and the legal guardian. The lack of supervision and failure to intervene allowed the incident to occur, resulting in a situation where two severely cognitively impaired, legally incapacitated residents were left vulnerable to sexual abuse.
Removal Plan
- Residents were immediately separated.
- Resident R909 was escorted to the nursing station for supervision.
- Resident R910 was placed on one-to-one supervision for safety and continued monitoring.
- Administrator was notified by the nurse.
- Physicians, legal guardians, and the ombudsman were notified.
- Police were called to the facility, arrived on site, and interviewed both residents.
- Pain and skin assessments were attempted on both residents.
- Physicians completed a Capacity for Sexual Consent/Intimacy Evaluation on both residents.
- Capacity results were shared with both residents and their legal guardians along with counsel on safe sex practices.
- Staff were educated on the capacity results.
- Care plans updated to reflect the determination that both residents were deemed cognitively able to consent to sex, their desire, and interventions to ensure privacy, safety and dignity.
- If either resident is likely to seek out other residents for non-exclusive sexual behavior, the facility's approach to limiting access to residents who are unable to consent includes providing staff education and increasing supervision as necessary.
Failure to Provide Adequate Supervision and Assistance Leads to Preventable Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, who required extensive assistance for all activities of daily living (ADLs), experienced a preventable fall resulting in a closed fracture of the distal end of the left femur and pain. The resident was dependent on staff for bed mobility and toileting, with care plans and the Kardex specifying the need for two-person assistance for both tasks. Despite these documented requirements, a certified nursing assistant (CNA) provided incontinence care alone, during which the resident rolled off the bed and sustained multiple injuries, including skin tears and a fracture. The facility's investigation revealed that the CNA misunderstood the difference between bed mobility and toileting assistance, believing that only one person was needed for toileting care, even though the resident was being cared for in bed. Documentation in the care plan and Kardex consistently indicated the need for two-person assistance for both bed mobility and toileting, but there was also a contradictory intervention stating dependency with one staff, which may have contributed to the confusion. The interdisciplinary team failed to identify and resolve these conflicting interventions, resulting in unclear and imprecise guidance for staff. Interviews with facility staff, including the CNA involved and the Administrator, confirmed that the CNA was aware of the two-person requirement for bed mobility but not for toileting, and proceeded to provide care alone. The Administrator acknowledged the oversight in the investigation and the failure to ensure that clear and precise interventions were implemented to maintain resident safety and prevent accidents. The facility's policy required systematic identification and mitigation of hazards, but this was not effectively carried out in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
CNA Worked with Lapsed Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained an active certification while working, as required by state law. Review of the CNA's personnel file showed that their certification had lapsed, and timecard records confirmed that the CNA continued to work in the facility with the expired certification on multiple dates. Attempts to interview the CNA were unsuccessful. The Administrator acknowledged awareness of the lapse after being informed by Human Resources, who only discovered the issue when the survey team requested the CNA's file. No further explanation or documentation regarding the lapse was provided by the end of the survey.
Medication Administration Failure
Penalty
Summary
The facility failed to protect the rights of 11 residents by not administering prescribed medications on the evening of February 25, 2025. This incident involved a nurse who was mandated to stay over their shift but did not pass any medications to residents on the first floor during that time. The Director of Nursing (DON) reported that the nurse was on the phone with the pharmacy regarding a new admission and did not administer the medications. As a result, several residents did not receive their scheduled medications, including those for critical conditions such as dementia, myocardial infarction, and other chronic illnesses. Resident 19, who was admitted with diagnoses including dementia and myocardial infarction, did not receive multiple medications, including Melatonin, Seroquel, Apixaban, Hydrocodone-Acetaminophen, and Lorazepam Gel. The facility's records showed that the nurse responsible for administering these medications was terminated due to negligence. The DON and other staff were notified, and the residents were monitored for any changes in condition, although no adverse reactions were noted at the time. The facility's investigation revealed inconsistencies in the electronic medication administration record (EMAR) documentation, indicating that medications were not consistently signed as given. The acting facility administrator, who was not in position at the time of the incident, acknowledged the neglectful nature of the event. The facility's policy on abuse, neglect, and exploitation defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, which was evident in this case.
Failure to Report Neglect Due to Medication Omission
Penalty
Summary
The facility failed to report an incident of neglect to the State Agency involving 11 residents. On a specific date, a nurse was mandated to stay over their shift but did not administer medications to residents on the first floor during that time. The Director of Nursing (DON) later discovered that multiple medications were not administered, including Melatonin, SEROquel, Apixaban, Hydrocodone-Acetaminophen, and Lorazepam for one resident. The nurse was reportedly on the phone with the pharmacy regarding a new admission and was subsequently terminated for negligence. The facility's investigation revealed inconsistencies in the electronic medication administration record (EMAR) documentation, indicating that medications were not consistently signed off when ordered. The DON did not initially identify the incident as neglect, and it was not reported to the State Agency. The acting facility Administrator, who was not in position at the time of the incident, later reviewed the case and believed it was neglectful. The facility's policy requires reporting all alleged violations to the appropriate authorities within specified timeframes, which was not adhered to in this case.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a resident was assessed for the safe self-administration of medication. During an observation, a resident was found holding a small vial for a breathing treatment, with a nebulizer machine nearby. The resident confirmed that they were self-administering the treatment, which was given to them by a nurse. However, a review of the clinical records showed no assessment, care plan, or physician order indicating that the resident was capable of safely self-administering their medication. The resident, who was admitted with diagnoses including schizoaffective disorder, heart failure, COPD, asthma, and dyspnea, had a BIMS score indicating intact cognition. Despite this, the facility's policy requires an interdisciplinary team assessment, a physician order, and a care plan for self-administration, none of which were present. Interviews with the DON and Nurse 'C' revealed a lack of adherence to the facility's policy, as the nurse admitted to allowing the resident to self-administer the treatment without proper documentation or oversight.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of a resident, identified as R39, who expressed a desire to take a shower rather than receive bed baths. R39, who was admitted to the facility in October 2024, has a diagnosis of schizoaffective disorder, bipolar disorder, difficulty walking, and morbid obesity. Despite having a high cognitive function as indicated by a BIMs score of 15, R39 was unable to take a shower because their wheelchair did not fit into the shower room. The Director of Nursing (DON) acknowledged the issue and stated that they would investigate the situation. However, as of the survey exit, no solution had been implemented to accommodate R39's preference for a shower.
Failure to Annually Reaffirm DNR Order with Guardian
Penalty
Summary
The facility failed to ensure an updated annual review of a Do-Not-Resuscitate (DNR) order with a legal guardian for a resident with moderately impaired cognition and multiple mental health diagnoses, including major depressive disorder, schizoaffective disorder, and bipolar disorder. The resident, who had a legal guardian, was admitted and readmitted to the facility with a DNR status. However, the facility did not document any communication between the resident's guardian and the attending physician regarding the reaffirmation of the DNR order, which is required annually according to state law. During an interview, the facility's social worker admitted to being unaware of the requirement for an annual review of a DNR order executed by a guardian. The facility's policy on residents' rights regarding treatment and advance directives, revised in February 2025, did not address the specific requirements for guardians to reaffirm the DNR order annually or the necessary communication between the guardian and the physician. This oversight led to the deficiency identified by the surveyors.
Failure to Maintain Resident Privacy Due to Missing Curtain
Penalty
Summary
The facility failed to protect the personal privacy of two residents, identified as R1 and R5, by not maintaining a privacy curtain between their beds. On March 18, 2025, it was observed that the privacy curtain was missing, with only the mesh top part attached to the ceiling track, while the solid part, which provides privacy, was absent. R1, who has moderately impaired cognition and requires assistance for activities of daily living (ADLs), reported that the curtain had been removed for cleaning and had been missing for an unspecified period. R5, who has severely impaired cognition and is dependent on staff for ADLs, was also affected by the absence of the privacy curtain. Interviews with facility staff revealed a lack of awareness and communication regarding the availability of extra privacy curtains. The Housekeeper, Environmental Services Manager, and Housekeeping Supervisor were unaware of the missing curtain and did not know who had removed it. The Housekeeping Supervisor and Laundry Aide indicated that there were no extra curtains available, and the process of laundering the curtains took several hours. However, the Regional Director of Operations stated that extra curtains were available and should have been used to maintain privacy. This discrepancy highlights a breakdown in communication and procedure within the facility, leading to a failure to ensure resident privacy during ADL care.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, identified as R44, who was observed on multiple occasions with a pile of hair under their bed. On March 18, 2025, R44 was seen lying in bed with a mechanical lift sling positioned under them, and a bottle of shampoo/body wash was on the windowsill. Despite the resident being transferred to a local hospital later that day, the pile of hair remained under the bed when observed again on March 19, 2025. The facility's housekeeping supervisor confirmed that routine daily cleaning should include sweeping the entire floor, including under the bed and behind furniture, which was not done in this case. R44 had been admitted to the facility with diagnoses including metabolic encephalopathy, vascular dementia, and anxiety disorder, and required staff assistance for activities of daily living due to severely impaired cognition. A review of R44's records indicated they received a bed bath on March 17, 2025, but the CNA responsible for the bath denied cutting the resident's hair. Another CNA assigned to R44 on March 18, 2025, did not return a call for clarification. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the unclean condition of the resident's room.
Failure to Transcribe Hospital Medication Orders
Penalty
Summary
The facility failed to correctly transcribe medication orders from the hospital for a resident, resulting in the resident missing prescribed dosages of an antibiotic medication. The resident, who was admitted to the facility with a diagnosis of vascular dementia, history of falling, and aphasia, was discharged from the hospital with instructions to receive Ciprofloxacin 500 mg every 12 hours for 5 days. However, upon review of the medical administration record, it was found that the antibiotic was not transcribed, and there was no progress note indicating that the physician had discontinued the treatment. Interviews with the facility's Infection Control Preventionist (ICP) and the Director of Nursing (DON) revealed that the hospital paperwork was received on February 17th, and the ICP noticed the missing antibiotic order but had not yet contacted the physician. The DON confirmed that medications should be transcribed as ordered from the hospital, and any changes made by a provider should be documented in a progress note. The deficiency was identified during a survey, and no additional information was provided at the exit of the survey.
Failure to Submit Change in Condition Form for Resident with Schizophrenia
Penalty
Summary
The facility failed to submit a Change in Condition level one screening Form DCH 3877 to the local Community Mental Health Services Program for a level two OBRA evaluation upon a change in a resident's condition. The resident, identified as R61, was admitted with a new diagnosis of schizophrenia, which was not included in the Minimum Data Set (MDS) assessment. Despite the resident's physician orders indicating the use of Seroquel for schizophrenia, the facility did not complete the necessary change of condition form upon the resident's readmission. The deficiency was identified during a survey when the Social Services Manager was questioned about the submission of the change in condition form. The manager admitted that the form had not been submitted until the day of the survey, citing a focus on other concerns. The facility's policy requires the Social Services Director to track each resident's PASARR screening status and promptly refer any resident with a newly evident serious mental disorder for a level II resident review, which was not adhered to in this case.
Failure to Complete PASARR Level II Evaluation After 30-Day Exemption
Penalty
Summary
The facility failed to ensure a Preadmission Screening/Annual Resident Review (PASARR) was submitted and completed by the local community mental health agency after the 30-day exemption period for a resident diagnosed with schizoaffective disorder. The resident was admitted with a hospital exemption, anticipating a stay of no more than 30 days, which did not require a Level II evaluation prior to admission. However, the resident remained in the facility beyond the exemption period, and the facility did not identify or submit a change in condition to the local community mental health agency for a Level II evaluation. The clinical record inaccurately documented that a Level II PASARR had been issued, which was not the case. The Social Services Manager was unable to explain the discrepancy and only submitted the Level II evaluation on the day of the surveyor's review. The facility's policy requires that if a resident remains in the facility longer than 30 days, a Level I screening should be conducted, and if necessary, a Level II evaluation should be referred to the appropriate state authority within 40 days of admission. This process was not followed, leading to the deficiency.
Failure to Ensure Professional Standards in Diagnostic Practices
Penalty
Summary
The facility failed to ensure that diagnostic practices met professional standards for a resident who received a new diagnosis of schizophrenia. The resident, who was admitted and readmitted with a new diagnosis of schizophrenia, had intact cognition according to the Minimum Data Set (MDS) assessment. However, the schizophrenia diagnosis was not included in the MDS assessment, and there was no documented clinical rationale or DSM-5 criteria for this new diagnosis. The resident had previously been diagnosed with Parkinson's disease, which was later disputed by a neurologist who suspected vascular dementia. Despite this, the resident was prescribed Seroquel for schizophrenia without further clarification or follow-up from psychiatric evaluations. Interviews with facility staff, including the Social Services Manager and the Director of Nursing, revealed a lack of awareness and follow-up regarding the resident's new schizophrenia diagnosis. The Social Services Manager was unaware of the diagnosis and had not scanned recent psych consultations into the medical record. The Director of Nursing was informed of the concerns but did not provide additional documentation or follow-up by the end of the survey. The facility was unable to provide a policy regarding professional standards for diagnostic practices, indicating a deficiency in maintaining professional standards of quality in diagnostic practices.
Failure to Implement Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide effective and timely interventions for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had a history of heart failure and dysphagia, was identified as being at moderate risk for skin breakdown according to a Braden scale assessment. Despite this, the resident was observed on multiple occasions without necessary offloading devices such as pillows or wedges to relieve pressure on their coccyx area. Additionally, the resident reported pain from a bed sore and indicated that staff had not applied the prescribed zinc barrier ointment, as they were unable to locate it. Further observations revealed that the resident's coccyx area had multiple open sores, and no barrier cream or treatments were present on the wounds. The wound care orders, which included zinc oxide treatment with normal saline solution, were not appropriately transcribed to the treatment administration record (TAR), resulting in a lack of proper wound care. The wound care nurse confirmed that the resident should have had offloading devices and that the treatment should have been applied to the coccyx area. The failure to implement these interventions and accurately assess the resident's wounds contributed to the deficiency in care.
Failure to Maintain a Hazard-Free Environment for Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, R28 and R61. R28 was observed on two occasions seated in a wheelchair with oxygen actively in use via nasal cannula, while a large container of petroleum jelly was present on their overbed tray table. The presence of petroleum jelly, a flammable substance, in close proximity to oxygen therapy posed a significant safety risk. Despite multiple staff members entering and exiting the room, the hazardous situation was not identified or addressed until it was brought to the attention of the Regional Director of Operations (RDO 'A'). R61's room was found to have multiple bottles stored on the window sill, including a bottle of Microban Bathroom Cleaner, which is classified as hazardous under OSHA regulations. The cleaner poses potential health risks, such as skin irritation and harm if swallowed or inhaled. The Maintenance Director acknowledged that the cleaner was likely brought in by the resident's wife, but staff should have noticed and removed it. The facility's policy requires that chemicals be properly stored and not left unattended in areas accessible to residents, which was not adhered to in this case.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident, identified as R61, who had multiple mental health diagnoses including unspecified dementia, mood disorder, and a new diagnosis of schizophrenia. The resident's spouse was initially documented as having legal guardianship, but the documentation had expired, and there was no current confirmation of guardianship status. The social services manager, SW 'D', was unaware of the new schizophrenia diagnosis and had not ensured follow-up on the resident's mental health needs or guardianship status. The resident had been receiving antipsychotic, antianxiety, and antidepressant medications, and there was a lack of clarity regarding the schizophrenia diagnosis. A psychologist's consultation suggested the resident might have Parkinson's dementia or fronto-temporal dementia, but there was no follow-up to clarify the schizophrenia diagnosis. The social services manager admitted to not being aware of the new diagnosis and had not scanned recent psych consultations into the medical record. The facility's policy required the provision of medically-related social services, including advocating for residents and ensuring they have a legal representative. However, the social services manager failed to identify the expired guardianship and did not ensure the resident's mental health needs were addressed. The lack of documentation and follow-up on the resident's guardianship and mental health needs led to the deficiency identified during the survey.
Failure to Document Medication Irregularities and Physician Responses
Penalty
Summary
The facility failed to ensure that irregularities identified by the consultant pharmacist during monthly drug regimen reviews were documented and available for review. This deficiency was noted for one resident, who had been admitted with multiple diagnoses including unspecified dementia, mood disorders, and anxiety. The resident's medication regimen reviews from April 2024 to March 2025 indicated several irregularities, but the specific details of these irregularities and the physician's responses were not documented in the clinical record. The facility's policy requires that any irregularities identified by the pharmacist be communicated both verbally and in writing to relevant staff and become a permanent part of the resident's medical record. However, during the survey, it was found that the facility did not have documentation of the specific pharmacy recommendations or physician responses for the identified irregularities. Despite requests for this information, the facility was unable to provide the necessary documentation by the end of the survey.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications for two residents. On multiple occasions, a prescribed Dermarite periguard ointment was observed unsecured on a bedside table in the room of one resident, R19, but labeled with another resident's name, R37. This ointment was left unattended and accessible, contrary to the facility's policy that medications should be stored securely and only accessible to authorized personnel. Despite being observed on different days, the ointment remained unsecured until a nurse was informed and removed it. The facility's policy clearly states that medications and biologicals must be stored safely and securely, with access limited to nurses, pharmacists, and pharmacy technicians. The failure to adhere to these policies resulted in the medication being improperly stored and labeled, leading to a deficiency in medication management and storage practices.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident, identified as R58, who was admitted with diagnoses including subdural hemorrhage and dementia. On March 6, 2025, a physician ordered several lab tests for R58, including a CBC with differential, CMP, HA1C, PSA, lipid panel, vitamin D level, and Keppra levels, due to conditions such as hypertension, benign prostatic hyperplasia, seizure, hyperlipidemia, generalized weakness, and a history of falling. However, upon review of R58's medical record, it was found that there were no results for the labs ordered on that date. On March 20, 2025, the Unit Manager Nurse V was questioned about the missing lab results and, after reviewing R58's record and checking the laboratory portal, indicated that a requisition for the lab tests was never made. Nurse V explained that during the time the lab order was supposed to be processed, the medical provider for R58 was switched to a different provider, and the nurses missed processing the lab order.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate and updated wound care evaluations and treatments in the medical record for a resident, resulting in the potential for misidentification and inappropriate wound care treatments. The resident, who had diagnoses including congestive heart failure and chronic obstructive pulmonary disease, reported a sore on their leg that was not healing. Upon review, discrepancies were found in the wound care orders documented by Medical Provider W. Initially, the wound care orders included the use of hydrogel with Xeroform, but this was later changed to Xeroform only due to concerns about excessive moisture. However, subsequent evaluations on 2/25 and 3/5 incorrectly included hydrogel in the treatment plan. Wound Care Nurse C confirmed that the wound practitioner had discontinued the hydrogel treatment, but the medical records still reflected its use. Medical Provider W acknowledged the error in the evaluations and stated that the hydrogel treatment should not have been included, indicating a need to correct the evaluations and update the clinical record.
Failure to Provide Proper Beneficiary Notices
Penalty
Summary
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for three residents, resulting in them being uninformed about potential private pay charges and their inability to file an appeal. The review of documentation revealed that for Resident 44, there was no SNFABN completed when the payer source changed from Medicare A to private pay. Similarly, for Resident 49, the facility used an outdated version of the NOMNC, and no SNFABN was completed when the payer source changed from Medicare A to Medicaid. For Resident 59, neither the NOMNC nor the SNFABN was completed upon the most recent completion of skilled care services. Interviews with facility staff revealed confusion and changes in the process of completing these forms. Nurse 'C' indicated that the process had changed recently and was now managed by the Business Office. Staff 'E', who recently took over the responsibility for beneficiary notices, reported that there had been several changes in the process and acknowledged the use of incorrect forms and the lack of SNFABN notices for residents who remained in the facility. The facility's policy documentation only included instructions for completing the SNFABN, without comprehensive guidance on the NOMNC.
Staffing Deficiency Leads to Unmet Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing for approximately 43 residents on the second floor, leading to potential unmet care needs. The deficiency was identified through interviews and record reviews, revealing that the facility was understaffed, particularly during the midnight shift. The facility's Scheduler stated that staffing was based on Per Patient Daily (PPD) numbers and budget, rather than the acuity of the unit. On multiple occasions, the midnight shift had fewer than the required three CNAs, and on one specific night, no CNAs were assigned to the second floor, leaving two nurses to perform both nursing and CNA duties for 43 residents. The residents on the second floor had high acuity needs, with diagnoses including dementia, dysphagia, mental and behavioral disorders, and many required assistance with all Activities of Daily Living (ADLs). Interviews with CNAs revealed that residents were not being adequately cared for, with reports of neglect and unmet needs due to insufficient staffing. The facility's Administrator acknowledged the staffing issues but cited budget constraints and recent terminations as contributing factors. The facility lacked a policy on sufficient staffing, and there was no documentation of specific staffing needs for each shift or unit.
Failure to Address Grievance Regarding Resident's Holiday Visit
Penalty
Summary
The facility failed to adhere to its grievance policy and adequately address a family member's concerns regarding a resident's inability to visit family on Christmas Day. The resident, who required a Geri chair for transport due to dementia and mobility issues, was expected to visit family at 1 PM but did not arrive. The family was informed by the facility that the resident could not be transported because the van could not accommodate the Geri chair. Despite the family reaching out to the facility's social worker multiple times, their calls were not returned, and no follow-up was conducted. The facility's social worker acknowledged being informed of the transportation issue but failed to document the incident or follow up with the family. The facility's grievance policy mandates prompt efforts to resolve grievances, including documenting and addressing complaints, which was not done in this case. The administrator was unaware of the family's concerns and stated that no grievances were recorded for the resident, indicating a breakdown in communication and policy adherence.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving residents with cognitive impairments and behavioral issues. Resident R605, who had severe cognitive impairment and a history of agitation, was involved in several altercations. On one occasion, R605 was slapped by R606 after calling her a derogatory name. R606, who had intact cognition, admitted to the act and was subsequently arrested. Despite R605's documented behavior of using derogatory language, there were no additional interventions implemented to address this behavior. Further incidents involved R605 being pushed by R611 and hit by another resident, R610. R611, who also had severe cognitive impairment and a history of verbal altercations, pushed R605 after being called a derogatory name. The facility's investigation noted that R605's behavior of calling people names was care planned, yet the supervision intended to prevent such incidents was inadequately implemented. R605 was supposed to be on 1:1 supervision, but records showed inconsistencies in staffing and supervision, with no staff assigned for 1:1 supervision on several days. Another incident involved R610 hitting R609 with a shoe. R609, who had severe cognitive and sensory impairments, was unable to defend themselves or explain the incident. R610 had a history of aggressive behavior and multiple room changes due to conflicts with roommates. Despite this history, R610 was placed in a room with R609, leading to the altercation. The facility's failure to adequately assess and plan for the behavioral needs of these residents contributed to the incidents of abuse.
Inadequate Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving two residents. Resident R608 alleged that resident R605 hit her in the head. The incident was reported to a Licensed Practical Nurse (LPN 'F') two days after it allegedly occurred. R608 identified R605 as the perpetrator, although the incident was not witnessed. The facility's investigation concluded that abuse was not substantiated, but they accepted R608's account of being hit. However, the investigation was limited as it did not include interviews with other staff or residents who might have had knowledge of the incident. The facility's policy on abuse, neglect, and exploitation requires identifying and interviewing all involved persons, including the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegations. Despite this, the investigation only involved an interview with LPN 'F' and did not extend to other potential witnesses or affected residents. The Administrator, who was the Abuse Coordinator, confirmed that no other residents or staff were interviewed to determine if others had been affected by R605's verbal or physical behaviors. This lack of thorough investigation led to the deficiency noted in the report.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement care planned interventions for a resident's bed mobility and toileting needs, and did not develop a care plan to address the resident's combative behaviors and hearing deficits. The resident, who had severe cognitive impairment, was blind, hard of hearing, and known to be combative during activities of daily living (ADL) care, sustained a skin tear on the left hand. The incident was reported to have occurred when a CNA was providing care, and the resident became combative. The CNA involved in the incident reported that the resident was blind and hard of hearing, and would become combative if care took too long. The CNA admitted to holding the resident's hands to their chest while completing care, which was against the care plan that required two-person assistance for bed mobility and toileting. The CNA believed they could handle the resident alone, despite the care plan's instructions. Interviews with facility staff, including the LPN and RN, confirmed that the resident was often combative and required two-person assistance for care. The care plan was not updated to address the resident's hearing deficit until after the incident occurred. The Director of Nursing (DON) stated that CNAs should follow the care plan and Kardex for the level of assistance required, and that a CNA should not determine a lesser level of assistance without an assessment.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in the resident eloping from the facility. The resident, who had a history of dementia, mood disturbance, anxiety, stroke, muscle weakness, history of falls, and malnutrition, was able to exit the facility through the front door and was found near a bus stop by a Registered Nurse (RN) who was leaving after their shift. The resident was outside for approximately five minutes, and the facility staff were unaware of the resident's absence until the RN intervened. The investigation revealed several deficiencies in the facility's supervision and alarm systems. The front door had an egress alarm with a 15-second delay, but the alarm was not loud enough to be heard by staff beyond the receptionist desk, which was not staffed after 6 PM or on weekends. The facility's investigation did not include witness statements from the nurse and CNA assigned to the resident on the day of the incident, nor did it provide a root cause analysis. Interviews with staff indicated that the alarm system was inadequate, and there was no designated staff to monitor the doors after hours. The resident's care plan and elopement assessments were not adequately updated to reflect the resident's risk of elopement, despite previous assessments indicating such risks. The facility's policy on elopement and wandering was not effectively implemented, as staff were not vigilant in responding to alarms, and the facility lacked a systematic approach to monitoring residents at risk for elopement. The facility administrator acknowledged the deficiencies in the alarm system and supervision but did not provide a clear explanation of how the facility would address these issues with the current staffing levels.
Failure to Implement Resident Care Plan Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent injury for a resident, resulting in a fracture of the right medial malleolus. The incident was reported when a Certified Nursing Assistant (CNA) noticed a bruise on the resident's right ankle during a range of motion exercise. The resident, who has a history of dementia and spastic hemiplegia, was found to be in significant pain, and it was noted that her wheelchair lacked foot pedals, which could have contributed to the injury. Additionally, the resident was supposed to wear a Prafo boot daily, but it was not located or worn prior to the incident. The facility's investigation revealed that the staff did not follow the care plan, which included ensuring the resident's feet were not dragging on the ground when in a wheelchair and applying the Prafo boot. The CNA involved in the incident reported that they had never seen the boot applied to the resident's foot before the injury. Furthermore, the CNA admitted that they did not ensure the wheelchair's footrest was applied, which could have prevented the resident's foot from dragging. The facility's education records showed that multiple staff members, including the CNA involved, had not been educated on the proper use of resident devices and foot pedals. The Administrator, who also serves as the facility's Abuse Coordinator, acknowledged the failure to implement the care plan interventions and the lack of staff education. The Administrator was newly hired and discovered these deficiencies during the investigation but did not provide further documentation or explanation by the end of the survey.
Failure to Report Injuries and Suspected Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency was identified when the facility did not report a black eye of unknown source for a resident and inaccurately reported an ankle fracture for another resident to the State Agency (SA). The facility's policy on abuse, neglect, and exploitation, revised in June 2023, outlines the need for thorough documentation and reporting of physical injuries of unknown source, which was not adhered to in these cases. In the first case, a resident with severe cognitive impairment was observed with a fresh bruise under their left eye. Despite the bruise being noted by nursing staff, it was not reported to the SA within the required two-hour timeframe. The Licensed Practical Nurse (LPN) who first noticed the bruise did not notify the Administrator immediately and instead endorsed it to the next shift nurse. The Administrator, who was informed later, chose to delay reporting to gather more information, which was against the facility's policy. In the second case, a resident with severe cognitive impairment and a history of dementia and spastic hemiplegia was found to have a bruise on their right ankle. The facility submitted an investigation to the SA that only noted the bruise, failing to report the fracture identified by the hospital. The Administrator claimed unawareness of the fracture, despite hospital documentation and nursing notes indicating its presence. This failure to accurately report the injury to the SA was a significant oversight in the facility's reporting obligations.
Failure to Document Resident Transfer and Discharge
Penalty
Summary
The facility failed to ensure the required documentation for the transfer of a resident, identified as R401, was noted in the medical record. R401 was admitted with serious medical conditions including acute respiratory failure with hypoxia, acute kidney failure, hypertension, atrial fibrillation, and severe sepsis, requiring assistance for all Activities of Daily Living (ADLs). The resident was transferred to another facility after five days, but there was no documentation in the medical record justifying the transfer or discharge, nor was there a discharge summary provided to the receiving facility. The facility's policy on transfer and discharge requires obtaining physician orders and completing a discharge summary, which was not adhered to in this case. The Previous Director of Nursing (PDON) noted that the resident's family was excited about the transfer and that the medication list was faxed, but there was no documentation of a physician's consultation or discharge orders. Additionally, there was no evidence of transportation arrangements being made by the facility, as the resident was transferred in a family car. Interviews with facility staff, including the Social Worker, Unit Manager, and interim Director of Nursing, revealed a lack of awareness and documentation regarding the transfer. The staff could not recall any specific concerns or reasons for the transfer, and the interim DON confirmed the absence of discharge orders and transportation arrangements. The facility did not provide any further explanation or documentation by the end of the survey.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that a medication ordered by the physician was obtained and administered for a resident, identified as R401, upon their admission. R401 was admitted with serious medical conditions including acute respiratory failure with hypoxia, acute kidney failure, hypertension, atrial fibrillation, and severe sepsis, requiring assistance for all Activities of Daily Living (ADLs). Hospital documents provided to the facility upon admission included an order for Acetylcysteine (Mucomyst 10%) 200 mg nebulized inhalation twice a day. However, the medication was not ordered on the day of admission, and the first dose was not administered until the following day, with the last dose recorded on 6/10/24. Despite multiple nurses signing off on the administration of the medication, a nursing note indicated that the medication was not available. The interim Director of Nursing (DON) confirmed that the admitting nurse did not implement the order on the day of admission, and the medication was ordered the next day. The pharmacy confirmed that the medication was never delivered. No further explanation or documentation was provided by the end of the survey, indicating a lapse in the facility's medication management process.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an incident where one resident pushed another to the ground, causing a head injury and necessitating hospital transfer. The incident involved a resident with a history of aggressive behavior and severely impaired cognition, who pushed another resident with dementia and osteoporosis, leading to a laceration on the head and bruising on the leg. The facility's report indicated that the incident occurred when the aggressive resident felt their personal space was invaded. The facility's investigation concluded that abuse was not substantiated, despite confirming that the aggressive resident pushed the other, causing the fall. The facility's policy defines abuse as the willful infliction of injury, but the administrator believed that if both residents had dementia, it was not considered abuse. The facility's policy also emphasizes the need to identify and intervene in situations where abuse is likely to occur, ensuring staff are aware of residents' care needs.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Administrator and the State Agency in a timely manner for one resident. The resident, who had diagnoses including dementia and violent behavior, was observed with two black eyes and a bruise on the forehead. The incident was initially documented as an unwitnessed fall, with the resident found in a bed that was not theirs, exhibiting a hematoma on the forehead and a laceration on the nose. Despite these injuries, the facility did not report the incident as an injury of unknown origin. The Administrator, who also served as the Abuse Coordinator, was informed by the Director of Nursing (DON) that the resident had a fall. However, the documentation did not support this conclusion, as the resident was found in a bed rather than on the ground, and the incident was unwitnessed. The Administrator acknowledged that the situation should have been reported as an injury of unknown origin and communicated to the State Agency immediately. Interviews with the DON and other staff revealed a lack of clarity and communication regarding the incident. The DON was not aware of the resident's wandering behaviors and relied on information from other staff members, who also did not witness the fall. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but this protocol was not followed, leading to the deficiency.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as R608, who was reviewed for abuse. On the morning of June 25, 2024, R608 was observed with two black eyes and a bruise on their forehead, walking quickly down the hallway and not responding to questions. The resident's clinical record indicated a history of dementia and violent behavior, with a Minimum Data Set (MDS) assessment showing severely impaired cognition and physical and wandering behaviors. A progress note from June 13, 2024, documented an unwitnessed fall with injuries, including a hematoma on the forehead and a laceration on the nose, but the resident was found in a bed, not on the floor, and no fall was witnessed. The facility's investigation into the incident was inadequate, as it did not include interviews with staff or residents to determine how R608 sustained the injuries. The incident report was categorized as a fall, despite the lack of evidence supporting this conclusion. The Director of Nursing (DON) relied on information from a nurse, without further investigation, to determine the cause of the injuries. The DON was unaware of R608's wandering behaviors and could not explain how it was determined that the pool of blood found was from R608. The facility's policy on abuse, neglect, and exploitation required an immediate investigation for injuries of unknown origin, but this was not conducted. Interviews with the Administrator and the DON revealed a lack of thorough investigation into the incident. The Administrator, who was the Abuse Coordinator, acknowledged that the injuries should have been investigated further. The DON admitted to relying on second-hand information and did not conduct a comprehensive investigation to rule out abuse. The facility's failure to investigate the injuries as required by their policy resulted in a deficiency in addressing potential abuse or neglect of the resident.
Failure to Provide Individual Activities for Resident
Penalty
Summary
The facility failed to provide ongoing individual activities for a resident with severe cognitive impairment and physical limitations, resulting in a potential negative impact on their well-being. The resident, who was admitted with a diagnosis of nontraumatic subdural hemorrhage, dementia, receptive-expressive language disorder, and bilateral upper and lower contractures, was observed multiple times alone in a Geri chair, either asleep or awake, without engagement in any activities. Despite being nonverbal, the resident maintained eye contact when spoken to, indicating some level of awareness and potential for interaction. The Recreation Director acknowledged the lack of documented one-to-one activities for the resident and cited staffing challenges as a barrier to providing daily individual activities. The facility's policy requires an ongoing program to support residents' activity preferences and well-being, but the current staffing situation, with only two staff members assisting with activities, has hindered the implementation of this policy. The Nursing Home Administrator and Director of Nursing recognized the deficiency and mentioned plans to develop a new activities program, but no corrective actions were documented at the time of the report.
Failure to Ensure Environment Free from Sexual Abuse
Penalty
Summary
The facility failed to ensure an environment free from sexual abuse for two cognitively impaired residents, R49 and R75, who lacked the ability to consent to physical intimacy. On 3/26/24, R75 wandered into R49's room, and both residents were found by staff without any clothes on, in bed together. R49 reported that R75 had tried to touch them everywhere and that they had been yelling for help. Both residents were noted to have legal guardians and severe cognitive impairments, with R75 having a BIMS score of zero and R49 having a BIMS score of 11. The incident was reported to the State Agency, and the facility's investigation confirmed the occurrence. The CNA who discovered the situation reported that the door to R49's room was blocked with a wheelchair, and upon entering, found both residents undressed and holding each other. Immediate actions were taken to separate the residents and place them under supervision. Skin assessments were conducted, revealing no new skin issues for R49 and red scratches on R75's abdomen. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines sexual abuse as non-consensual sexual contact of any type with a resident. Despite the immediate actions taken post-incident, the facility's failure to prevent the initial occurrence of the incident highlights a deficiency in ensuring a safe environment for residents, particularly those who are cognitively impaired and unable to consent to physical intimacy.
Failure to Timely Submit Abuse Investigation
Penalty
Summary
The facility failed to submit their abuse investigation within the mandatory five business day time-frame for two residents. On 3/26/24, a staff member found one resident without clothes in another resident's room, who was also without clothes. Both residents were incapacitated with court-appointed legal guardians. The incident was reported to the State Agency on the same day, and the facility initiated an investigation immediately. The residents were separated, and one was placed on 1:1 supervision. Notifications were made to the Administrator, police department, physicians, and guardians. The police arrived and spoke with staff and the Administrator, who had already begun gathering staff statements. The facility investigator spoke with both residents and staff involved in the incident, and the investigation concluded that the incident occurred as described by the staff member who witnessed it. However, the facility did not submit the investigation to the State Agency until 4/9/24, which was beyond the mandatory five business day time-frame. The Regional Director of Operations (RDO) indicated that they were the Administrator at the time and conducted the investigation. The RDO believed the incident was reported in the correct time frame due to its sexual nature but admitted that the investigation was not submitted on time because they did not have access to submit it, and the new Administrator was unavailable. The RDO did not contact the State to gain access to submit the investigation within the required time frame. The facility's policy on abuse, neglect, and exploitation requires reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Protect Vulnerable Resident from Sexual Incident
Penalty
Summary
The facility failed to protect a vulnerable resident, who lacked cognitive ability to consent to sexual activity, from a sexual incident initiated by another resident who was cognitively intact. The incident involved a resident with severe dementia and Alzheimer's (R702) and a resident with intact cognition (R703). R703 was found naked in bed with R702, who was also naked, and had an erection. The facility staff did not respond appropriately to the incident, failing to notify law enforcement immediately and not preserving potential criminal evidence. The facility also failed to conduct a thorough investigation and did not ensure the safety of other vulnerable residents by allowing R703 to remain unsupervised on the same floor after the incident. The incident was first discovered by a CNA who found R703 in bed with R702. The CNA left the room to get a nurse, leaving R702 and R703 together. Upon returning, the nurse separated the residents and assessed R702, who complained of abdominal pain. Despite the severity of the situation, the facility staff did not preserve the bedding or clothing as evidence and did not notify law enforcement. The police were eventually called by EMS when R702 was sent to the emergency room. The facility's administrator did not come to the facility on the day of the incident and started the investigation the following day, failing to obtain immediate statements from the staff involved. The facility's investigation was incomplete, lacking thorough documentation and staff statements. The administrator failed to provide clear directives for monitoring and supervision of R703 after the incident, leaving other vulnerable residents at risk. The facility's policy on abuse, neglect, and exploitation was not followed, as the staff did not exercise caution in handling evidence or ensure the protection of all residents during and after the investigation. The facility's deficient practices resulted in an Immediate Jeopardy situation, which was later removed after the implementation of a removal plan, but the underlying issues remained uncorrected.
Removal Plan
- Current residents with BIMS scores of 8 and above will be interviewed/assessed for potential sexual abuse. Current residents with BIMS scores of 7 and below will be assessed by a licensed nurse for an acute change in condition. Any concerns that arise will be addressed by the IDT immediately.
- Resident 703 no longer resides in the facility.
- Resident 702 received wellbeing checks by the facility Social Worker and her Hospice RN. Resident has shown no deviation from baseline.
- The Abuse, Neglect & Exploitation Policy was reviewed by the Corporate Compliance Officer and deemed appropriate.
- The abuse investigation procedure was reviewed by the Corporate Compliance Officer and deemed appropriate.
- The Corporate Compliance Officer re-educated the facility Administrator on our Abuse, Neglect & Exploitation Policy, and the investigation procedure.
- All staff will be reeducated on the facility abuse policies, including abuse prevention and expected interventions. Education also includes preservation of potential crime scenes in the event of a sexual allegation. Any staff not educated will be educated prior to their next shift.
- In the event of any future resident sexual abuse allegations, the perpetrating resident will immediately be placed on 1:1 supervision until additional safety interventions can be implemented.
- The Medical Director was notified of this event.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving two residents, R702 and R703. R702, who had severe cognitive impairment due to Alzheimer's and dementia and was under hospice care, was found in bed with R703, who had intact cognition. R703 was discovered naked with an erection, while R702 was partially undressed and in a vulnerable position. The incident was reported by CNA A, who found the residents in this state and immediately informed RN B. Despite the immediate separation of the residents, the facility's response was deemed inadequate as R702 was left alone with R703 while CNA A went to get RN B, and the bedding was washed before police could examine it for evidence. R702's medical records indicated a BIMS score of 00, signifying severely impaired cognition and an inability to consent to sexual activity. R703, on the other hand, had a BIMS score of 14, indicating intact cognition and the ability to consent. The facility's policy on abuse, neglect, and exploitation clearly defines sexual abuse as non-consensual sexual contact of any type with a resident. The facility's failure to prevent this incident and the subsequent handling of the situation, including the washing of potential evidence, highlights significant lapses in protecting residents from abuse. The police report and hospital records corroborate the findings, with the police noting that R702 was unable to recall the incident due to severe dementia and was in pain, holding her stomach. The hospital's after-visit summary confirmed the reason for the visit as sexual assault. The facility's administrator acknowledged being notified of the incident on the day it occurred but stated that the investigation was still ongoing. The immediate actions taken included separating the residents and sending R702 to the hospital, while R703 was placed in police custody.
Failure to Report and Handle Allegation of Sexual Abuse Timely
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime, specifically an allegation of sexual abuse. The incident involved two residents, where one resident was found naked in bed with another resident, who was also partially undressed. The facility's staff did not report the incident to law enforcement within the required two-hour timeframe, and the facility's Administrator delayed reporting the incident to the State Agency (SA). This delay resulted in the inability of law enforcement and health officials to obtain and process evidence properly. The incident was first discovered by a Certified Nursing Assistant (CNA) who found the two residents in a compromising position. The CNA reported the situation to a Registered Nurse (RN), who then informed the facility's Administrator. However, the Administrator did not provide clear directives to preserve evidence or notify law enforcement immediately. The CNA and RN proceeded to clean the resident and dispose of the bedding, which compromised potential evidence. The local law enforcement was eventually notified by Emergency Medical Services (EMS) when one of the residents was sent to the emergency room for evaluation. Interviews with the facility staff revealed a lack of understanding and training regarding the proper procedures for handling and reporting such incidents. The Administrator admitted to not recalling whether they instructed the staff to call law enforcement and acknowledged the delay in reporting the incident to the SA. The facility's policy on abuse, neglect, and exploitation was not followed, leading to significant lapses in the handling of the incident and the preservation of evidence.
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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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