Harmony Village Of Warren
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Michigan.
- Location
- 11525 East Ten Mile Road, Warren, Michigan 48089
- CMS Provider Number
- 235259
- Inspections on file
- 29
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Harmony Village Of Warren during CMS and state inspections, most recent first.
Surveyors identified improper food storage and preparation practices, including moldy cardboard on the cooler floor, expired Italian dressing, a soiled ice scoop holder, and oatmeal served below the required hot holding temperature. These actions did not meet professional standards for food service safety.
A resident with cerebral palsy and impaired mobility was observed twice without accessible water in their room, once with the water cup out of reach and another time with no water cup present. The resident reported being unable to access water due to mobility limitations and fear of falling, and also noted that the water cup had been removed. The DON stated that fresh water should be available, but no facility policy on water provision was provided during the survey.
A resident who was discharged from Medicare Part A and remained in the facility did not receive a timely SNF/ABN notice informing them or their representative of potential financial liability for ongoing services. The Business Office Manager acknowledged the oversight, and the Administrator confirmed the expectation for timely notification.
The facility did not ensure that two residents with mental health diagnoses received appropriate PASARR Level II evaluations following a change in condition. One resident was not referred for a Level II evaluation despite a completed Level I screening indicating mental health diagnoses, and another resident's Level I screening was completed inaccurately, omitting relevant mental health information and recent antidepressant use. These actions did not comply with required PASARR procedures.
A resident with cognitive impairment and multiple diagnoses, including PTSD, did not have a care plan addressing PTSD despite documentation in two OBRA evaluations. The omission was acknowledged by both a social worker and the DON, and the facility's policy requires such diagnoses to be included in the care plan.
A resident with mood and depressive disorders was observed exhibiting distressing behaviors, and review of their care plan revealed outdated interventions referencing a psychiatric provider no longer involved in their care. Staff interviews confirmed the care plan had not been updated to reflect current treatment practices, and facility policy did not address updating interventions.
A resident with multiple chronic conditions, including hepatitis C and a history of polysubstance abuse, did not receive ordered gastroenterology and infectious disease consults for colonoscopy and hepatitis C management. Despite physician orders and the resident's agreement to the consults, the facility did not follow through, and the DON confirmed the consults were not completed.
A resident with a suprapubic catheter did not have timely catheter changes as prescribed, with observations of soiled and discolored tubing and no documentation of recent changes. Staff were unable to confirm when the last change occurred, and medical records lacked evidence of compliance with physician orders for catheter care.
The facility did not ensure that monthly medication regimen reviews were completed and documented by a licensed pharmacist for several residents, including those with complex medical conditions such as dysphagia, Alzheimer's, and heart failure. The July reviews were missing, and irregularity reports were not available when requested. The DON confirmed the missing documentation and was uncertain about the handling of irregularity reports, and the facility's pharmacy review policy was not provided during the survey.
An LPN crushed and administered delayed release and extended release medications, as well as an incorrect dosage of a cranberry tablet, to a resident with dysphagia and Alzheimer's, resulting in a medication error rate of 12.12%. The DON was notified, and the NP confirmed these medications should not be crushed, in accordance with facility policy.
The emergency egress path outside the staff entrance was found to be obstructed by construction activities, including broken ground, gravel, and barricades, which could delay or prevent evacuation during an emergency. This was confirmed by the maintenance director during the survey.
A delayed egress emergency exit door in the 300 unit did not activate its release process when pressure was applied, as observed by surveyors and confirmed by the maintenance director. This failure to comply with egress requirements could affect up to 30 occupants during an emergency evacuation.
Fire-rated cross corridor doors between the main lobby and main corridor hallway were found not to fully close, failing to resist the passage of smoke and fire as required. This deficiency, confirmed by the maintenance director, could affect up to 50 occupants by allowing smoke and fire to spread between compartments.
A portable space heater was observed running in the Human Resources Office, in violation of regulations prohibiting such devices in health care occupancies. The facility could not verify that the heater's element did not exceed the allowed temperature, and the maintenance director confirmed the finding.
A resident was not protected from physical abuse by staff, as determined through observation, interview, and record review. This failure resulted in Immediate Jeopardy and demonstrated noncompliance with federal requirements for freedom from abuse.
A resident with intact cognition reported being slapped and verbally abused by an LPN during care, with a CNA witnessing and attempting to intervene before leaving the room. The LPN continued working the remainder of their shift after the incident was reported. In a separate event, a resident with impaired cognition was slapped in the face by another resident in a common area, witnessed by a receptionist. Both incidents involved delays in immediate protective actions and reporting, resulting in substantiated abuse findings.
A resident with severe cognitive impairment and a legally appointed DPOA was discharged to an estranged family member without notifying or obtaining consent from the DPOA. Facility staff accepted a birth certificate and a phone confirmation from the resident's ex-wife, neither of whom were listed as contacts, and did not arrange for home care, physician follow-up, pharmacy, DME, or hospice services after discharge.
A resident with cognitive impairment was inappropriately touched by another resident in the dining room when no staff were present to supervise. The incident was witnessed by the Activities Director, who intervened immediately. Prior to the event, staff had discussed the perpetrator's sexual behaviors, but no formal reports were made to the DON. Both residents involved had significant care needs, and the lack of supervision enabled the incident.
The facility failed to maintain a clean and repaired environment, affecting all 126 residents. Observations revealed issues such as debris buildup in shower drains, rusted heater registers, soiled bedding, and damaged walls. Flooring was dull and discolored, with soil buildup at room entries. Interviews with the Administrator, DON, and Maintenance Director highlighted concerns about the building's condition, with maintenance staff being understaffed for most of the year.
A resident with diabetes and a history of stroke experienced high blood glucose levels, but the facility failed to notify the physician in a timely manner as required by policy. The resident's glucose levels were recorded as 450 mg/dl and 550 mg/dl, but the physician was only notified after the resident became lethargic and was sent to the hospital. The facility's policy required notifying the physician for readings over 400 mg/dl, which was not followed.
The facility failed to implement care plans for two residents, one with catheter care needs and another with dental pain, despite their intact cognition and specific medical conditions. The Director of Nursing acknowledged the absence of necessary care plans, which is against the facility's policy.
The facility did not maintain a safe environment for its 133 residents due to broken and missing floor tiles in the basement. The Maintenance/Housekeeping/Laundry Director initially claimed the tiles contained asbestos, but later expressed uncertainty. The Director admitted that corporate was not informed about the issue, and the Nursing Home Administrator was unaware of the potential asbestos. The facility also failed to provide an environmental policy on floor tiles.
A resident experienced a lack of clean linen and an unclean bathroom environment due to facility-wide linen shortages and maintenance issues. The resident reported not having their bed linen changed and was observed in a worn gown with a stained pillowcase. The bathroom had water leakage, mold, and dust buildup. The facility faced operational challenges with laundry equipment, and staff shortages in housekeeping, laundry, and maintenance contributed to the deficiency.
The facility failed to maintain accurate medical records and shower documentation for six residents. A nurse documented administering medications to a resident on leave, and there was a lack of shower documentation for seven residents over 14 days. Interviews revealed discrepancies between reported care and documented records.
Deficient Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed several deficiencies in food storage and preparation practices within the facility's kitchen. In the walk-in cooler, a large piece of cardboard was found on the floor beneath a rack holding milk crates, and the cardboard's surface was covered with a spotty, black mold-like substance. Additionally, an opened 1-gallon container of Italian dressing with a use-by date that had already passed was present in the cooler. The ice scoop holder in the dining room contained a black, slimy gel on the bottom inside surface, with the tip of the ice scoop resting in the gel. These conditions were not in accordance with professional standards for food service safety as outlined in the 2017 FDA Food Code. Further, during breakfast service, approximately 45 individual covered bowls of oatmeal were observed on a tray next to the steam table, not being held at the required hot holding temperature. At a later time, 6 bowls remained, and the internal temperature of the oatmeal was measured at 125 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot holding. The Food Service Manager was unable to provide an explanation for the failure to maintain the correct temperature. These findings demonstrate a failure to prepare, store, and serve food in accordance with professional standards, as required by federal regulations.
Failure to Ensure Accessible Water for Dependent Resident
Penalty
Summary
The facility failed to ensure that water was accessible to a resident who required assistance with activities of daily living and was at risk for falls and dehydration. On two separate occasions, the resident was observed in bed without water within reach; once, the water cup was on a dresser out of reach, and another time, the water cup was missing entirely. The resident reported being unable to reach the water and expressed concern about falling if attempting to get it, and later stated that someone had removed the water cup. The resident's medical record indicated diagnoses of cerebral palsy and difficulty walking, with a care plan identifying risks for falls and dehydration. The DON confirmed that fresh water should be available to residents, and the facility was unable to provide a policy regarding water provision before the survey concluded.
Failure to Issue Timely SNF/ABN Notice After Medicare Discharge
Penalty
Summary
The facility failed to provide a timely Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF/ABN) to a resident who had a Medicare Part A discharge and continued to reside in the facility. Record review showed that the resident did not receive the required notice informing them or their representative of potential financial liability for services not covered by Medicare. During interviews, the Business Office Manager acknowledged the oversight, and the Administrator confirmed that the notice should have been issued in a timely manner.
Failure to Complete and Refer PASARR Level II Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Preadmission Screening and Resident Review (PASARR) procedures were followed for two residents with mental health diagnoses. For one resident with hemiparesis, schizoaffective disorder, anxiety disorder, and major depressive disorder, a Level I PASARR screening was completed as a change of condition, but there was no evidence of a referral for a Level II evaluation or that such an evaluation was completed, despite the resident's mental health diagnoses. The social worker confirmed that the Level II evaluation was not done, and the nursing home administrator stated that PASARRs and Level II evaluations should be completed timely per policy. For another resident with major depressive disorder and generalized anxiety disorder, the PASARR Level I Change in Condition screening form was completed inaccurately, as it failed to document the resident's current mental illness diagnosis and recent use of prescribed antidepressant medication. The social worker acknowledged the form was completed incorrectly. The facility's policy requires that individuals with or suspected of having mental disorders be referred for a Level II PASARR evaluation, but this process was not followed for these residents.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident who had documented diagnoses of PTSD in two separate OBRA evaluations completed in 2024 and 2025. The resident was admitted with multiple diagnoses, including cerebral infarction, heart failure, and major depressive disorder, and was noted to be cognitively impaired and dependent on assistance for bathing and dressing. Despite these findings and the documented PTSD diagnosis, the resident's care plan did not include interventions or goals related to PTSD. Both the social worker and the DON acknowledged the omission when questioned, and the facility's policy requires that changes in a resident's mental or psychosocial functioning be incorporated into the care plan.
Failure to Update Psychiatric Care Plan Interventions
Penalty
Summary
A deficiency was identified when the facility failed to update the interventions on a psychiatric care plan for a resident with a history of mood disorder and major depressive disorder. The resident was observed awake in bed, yelling, screaming, and swearing. The electronic medical record showed the resident was prescribed Remeron for depression, and the most recent MDS assessment indicated moderately impaired cognition with no mood indicators. The psychiatric care plan listed an intervention involving follow-up by a specific psychiatric provider agency, but this agency was no longer involved in the resident's care. During interviews, the social worker confirmed that the care plan interventions had not been updated to reflect the current treatment practices, and the DON agreed that interventions should be updated as needed. A review of the facility's care planning policy did not address the updating of interventions when care planning, contributing to the failure to revise the care plan to match the resident's current psychiatric treatment arrangements.
Failure to Obtain Ordered Gastroenterology and Infectious Disease Consults
Penalty
Summary
The facility failed to obtain required gastroenterology and infectious disease consultations for a resident who was reviewed for consults. The resident was admitted with multiple diagnoses, including dysphagia, peripheral vascular disease, anxiety, hepatitis C, hepatitis B, COPD, severe protein calorie malnutrition, alcoholism, diabetes, insomnia, sinusitis, and thyroid disease. The resident was cognitively intact and independent in transfers and bed mobility. A physician progress note documented the need for chronic disease management, specifically hepatitis C, and discussed the need for a colonoscopy and GI follow-up, to which the resident agreed. Despite active physician orders for a gastroenterology consult for colonoscopy and a consult for evaluation and management of chronic hepatitis C, these consults were not carried out. The Director of Nursing confirmed that the consults had not been followed through. A review of the facility's physician orders and clarification orders did not show any documentation addressing the completion of these physician-ordered consults.
Failure to Ensure Timely Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure timely changing of a suprapubic (SP) urinary catheter for one resident. Observations revealed that the resident's catheter tubing appeared faded, soiled, and had areas of black discoloration, with the drainage tube clouded with sediment. Interviews with staff indicated uncertainty about when the last catheter change occurred, and the resident was unsure of their last urology visit or catheter change. Record review showed the last documented urology appointment was several months prior, with physician instructions for the SP catheter to be changed every six weeks. However, there was no documentation in the facility records of any recent catheter changes, and staff were unable to provide evidence of compliance with the prescribed change schedule. The resident had a history of heart failure, chronic kidney disease, and high blood pressure, and had been readmitted to the facility multiple times. The medical record included inconsistent or outdated orders regarding catheter type and size, and lacked clear documentation of catheter change timing. Despite requests, the Director of Nursing was unable to provide documentation of catheter changes prior to the survey exit. The facility's policy required clarification orders to initiate treatment according to the plan of care, but this was not followed in the case of the resident's catheter care.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews (MRRs) and followed up on physician notification of pharmacy recommendations for four out of five residents reviewed for unnecessary medications. Specifically, for one resident with diagnoses including dysphagia, peripheral vascular disease, and anxiety, the July MRR was missing from the medical record, and irregularity reports for several dates were not available upon request. The facility was unable to provide the requested MRRs and irregularity reports during the survey, despite multiple requests. Additionally, three other residents with diagnoses such as schizoaffective disorder, bipolar disorder, insomnia, dysphagia, Alzheimer's disease, heart failure, kidney disease, and hypertension also had missing July MRRs. The Director of Nursing confirmed that the July MRRs were never received and was unsure about the status of the irregularity reports, stating they had been given to unit managers. The facility's policy and procedure for pharmacy services related to pharmacy reviews was requested but not provided before the survey concluded.
Crushing of Delayed and Extended Release Medications and Incorrect Dosage Administration
Penalty
Summary
During a medication pass observation, an LPN prepared and crushed several medications, including one delayed release and two extended release medications, before administering them to a resident. The medications that were crushed and placed into applesauce included Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg and Metoprolol succinate 100 mg ER, both of which should not be crushed according to facility policy and standard medication guidelines. Additionally, a cranberry tablet was administered at an incorrect dosage (450 mg given instead of the ordered 400 mg). These actions resulted in a medication error rate of 12.12% out of 33 medications observed during the survey. The resident involved had diagnoses of dysphagia and Alzheimer's disease, required a mechanically altered diet, and needed substantial to maximal assistance with eating. The facility's policy on medication crushing, dated June 2019, specifically states that timed release tablets should not be crushed due to their design for sustained release and to reduce stomach irritation. The DON was made aware of the errors at the time of observation, and the Nurse Practitioner confirmed that delayed and extended release medications should not be crushed and was not previously aware that this practice was occurring.
Obstructed Emergency Egress Due to Construction
Penalty
Summary
The facility failed to maintain a clear and unobstructed means of egress as required by regulation. On May 6, 2025, at approximately 11:00 AM, observation revealed that the emergency egress path outside the staff entrance doors was under construction due to underground pipe replacement. The ground in this area was broken, filled with gravel, and barricaded to prevent foot traffic, which could delay or prohibit evacuation through these doors during an emergency. These findings were confirmed through an interview with the maintenance director at the time of observation.
Plan Of Correction
Element 1 On April 11, 2025, maintenance staff immediately cleared items and made a pathway for all cited exit areas, including the northwest exit and exit near Room 411. Signs were temporarily posted indicating caution until the area was verified safe and useable again. Element 2 All residents in units adjacent to and reliant upon the affected exits (northwest hallway and near Room 411) were assessed for potential risk. No residents experienced adverse effects as a result of the obstruction. Element 3 All maintenance and housekeeping staff were in-serviced on May 6, 2025, regarding the revised policy and procedures. Element 4 The Director of Maintenance or designee will audit all exits daily during week x5 days a week for a month, then once weekly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee monthly for review and further recommendations. The administrator is responsible for the sustained compliance.
Delayed Egress Door Fails to Release During Emergency Exit Test
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the door met the special locking arrangements for delayed egress as specified by regulations. Specifically, on May 6, 2025, at approximately 11:30 AM, it was found that the 300 unit delayed egress emergency exit door did not activate the delayed egress release process when pressure was applied to the door. This malfunction was directly observed and confirmed through an interview with the maintenance director at the time of the observation. This deficiency could affect up to 30 occupants in the event of an emergency evacuation, as the door's failure to release could prohibit or delay their exit. The report does not mention any specific residents or their medical conditions at the time of the deficiency, nor does it provide details about any immediate consequences resulting from the malfunction.
Plan Of Correction
Element 1: On May 16, 2025, maintenance staff installed highly visible signage ("Push to Exit" and "Emergency Exit Release") above and beside all magnetically locked egress doors. A staff member was assigned to test each door's emergency function to verify operability. Element 2: All residents were evaluated for reliance on egress doors for safe evacuation. No residents were affected by the magnetic locking system during the time of inspection. Element 3: All emergency exit devices were tested facility-wide for compliance. Staff training was conducted on May 16, 2025, to review emergency door operation, including the use of magnetic locks and identifying signage. Monthly egress drills will now include checks of all egress door systems, including magnetic locks. Element 4: The Maintenance Supervisor will conduct monthly tests of each egress door's emergency release function and verify signage placement and visibility. Audit results will be documented and reviewed in monthly Safety Committee meetings. Trends or failures will be escalated to QAPI for corrective planning. The administrator is responsible for the sustained compliance.
Fire-Rated Corridor Doors Failed to Close Fully
Penalty
Summary
Surveyors observed that the fire-rated cross corridor doors between the main lobby and the main corridor hallway did not fully close, which compromised their ability to resist the passage of smoke and fire. This observation was made during a facility inspection and was confirmed through an interview with the maintenance director at the time of the survey. The doors in question are required by regulation to resist the passage of smoke and, in certain cases, fire, to prevent the spread of hazardous conditions between compartments. The deficiency was specifically noted as affecting the protection of corridor openings, as the doors failed to meet the standards outlined in NFPA 19.3.6.3. The report states that this issue could impact up to 50 occupants in the event of a smoke or fire event, as the compromised doors would allow heat, smoke, and fire to pass into adjacent compartments. No information about individual residents' medical histories or conditions at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1 On May 14, 2025, maintenance personnel adjusted and repaired the door to Room 302 to ensure full closure and smoke resistance. A door sweep was installed on the door near Room 410 to eliminate the excessive gap. Element 2 A facility-wide audit of all corridor doors was completed on May 9, 2025. No other deficiencies in corridor door function were identified. All residents in proximity to the affected rooms were found safe and unaffected. Element 3 All facility doors were checked for compliance with smoke resistance standards on May 14, 2025. Staff were educated on May 16, 2025, on reporting improperly closing doors to the maintenance department immediately. Element 4 The Director of Maintenance or designee will complete monthly corridor door inspections to ensure doors close and latch properly and resist the passage of smoke. Results will be recorded and reviewed during QAPI meetings. Any failure will prompt immediate repair and re-education. The administrator is responsible for the sustained compliance.
Portable Space Heater Found in Prohibited Area
Penalty
Summary
A portable space heater was found running in the Human Resources Office during an observation on May 6, 2025. The facility failed to ensure that portable space heating devices were prohibited in all health care occupancies, as required by regulations. Additionally, it could not be verified that the heating element of the space heater did not exceed 212 degrees Fahrenheit, as specified by code. The maintenance director confirmed these findings during an interview at the time of observation. This deficiency could potentially affect 15 occupants in the event of a space heater related fire, as noted in the report.
Plan Of Correction
Element 1 On May 6, 2025, the portable space heater identified in the Human Resources Office was immediately removed from the facility and placed in secure storage pending disposal. A sweep of all administrative, clinical, and non-clinical areas was conducted the same day to identify and remove any other unauthorized space heaters. None were found. The Maintenance Director confirmed removal and documented the action. Element 2 A full facility audit of all office, administrative, breakroom, and storage areas was completed to ensure no other prohibited portable heating devices were present. All residents were evaluated for potential risk exposure. No resident rooms or care areas contained space heaters, and no resident was adversely affected. Element 3 On May 8, 2025, the facility reviewed its Electrical Equipment and Fire Safety Policy. Education was provided to clearly state that all portable space heaters are prohibited, unless explicitly approved in writing by the Administrator and Maintenance Director and confirmed to not exceed 212°F and only used in nonsleeping staff areas. A mandatory in-service training was conducted on May 16, 2025, for all department heads, including Human Resources, Administration, Maintenance, and Nursing, regarding fire safety compliance and the prohibition of portable space heaters under NFPA 101. Element 4 Beginning May 16, 2025, the Director of Maintenance or designee will perform monthly environmental safety rounds, with documentation confirming no prohibited space heaters are in use. Any unauthorized heating devices found will be immediately removed and reported to the Administrator and Safety Committee. Compliance findings will be reviewed monthly during the facility's QAPI meetings for 6 months and quarterly thereafter. The administrator is responsible for the sustained compliance.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff, as identified through observation, interview, and record review. This incident involved one resident out of three reviewed for abuse and resulted in an Immediate Jeopardy situation. The report documents that the facility did not ensure the resident's right to be free from abuse, specifically physical abuse by staff, as required by federal regulations. The deficiency was substantiated by findings from the survey, which included direct evidence of the abuse and the facility's failure to prevent it. No additional details about the resident's medical history or condition at the time of the incident are provided in the report.
Plan Of Correction
F600 - Freedom from Abuse, Neglect, and Exploitation Deficient Practice #1: Failure to Protect Resident (R800) from Staff Abuse Element #1: Resident R800 received immediate emotional support from Social Services on 4/16/2025. Resident was assessed by nursing for physical injury and psychosocial trauma. Ongoing counseling and support have been arranged as requested by resident. Resident's care plan was updated to include Element #2. Element #2: On 4/16/2025, all residents with a BIMS of 8+ were interviewed for abuse concerns. Residents with BIMS <8 were assessed for known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3: LPN “E” was immediately suspended on 4/3/2025 and has not returned to the facility. CNA “C” and LPN “D” received 1:1 education.
Failure to Protect Residents from Physical and Verbal Abuse by Staff and Peers
Penalty
Summary
A resident with an intact mental status and a history of dysphagia and weakness reported to the Director of Nursing (DON) that they were slapped on the arm twice by their midnight nurse during care. The resident stated that the nurse was verbally abusive, refused to allow them to use the bathroom, and called them derogatory names. Another staff member, a Certified Nurse Assistant (CNA), was present during the incident and attempted to intervene but was met with aggression from the nurse and subsequently left the room. The CNA reported the incident to another nurse and contacted the facility administration at the end of their shift. The nurse accused of abuse continued to work the remainder of their shift after the incident. The facility's investigation revealed that the incident occurred during the early morning hours while the resident was experiencing acute illness symptoms. The nurse involved was not immediately removed from resident care and continued working until the end of their shift, despite the abuse allegation being reported to staff. The DON and Nursing Home Administrator (NHA) were informed of the incident later in the morning, and the nurse was suspended only after administrative review. The abuse was substantiated, and the resident expressed feeling unsafe and embarrassed as a result of the incident. In a separate event, another resident with impaired cognition was physically abused by a fellow resident in a common area. The incident was witnessed by a receptionist, who observed one resident approach and slap another in the face. The aggressor admitted to the act and expressed intent to repeat it. The incident was reported to the NHA, and the aggressor was subsequently sent for inpatient psychiatric care. Both incidents demonstrate failures in protecting residents from abuse by staff and peers, as well as lapses in immediate response and reporting protocols.
Plan Of Correction
On mandatory reporting, all staff, including nursing, activities, and ancillary services, were re-educated on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to the Abuse coordinator. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance. Deficient Practice #2: Failure to Protect Resident (R801) from Resident-to-Resident Abuse Element #1: R801 was physically assessed and found to have no visible injuries. Resident was offered and received psychosocial support by Social Services. Resident's safety plan and care plan were updated. Element #2: Review conducted of all residents residing in common areas with a history of aggressive behaviors. Resident R802 was identified and sent for psychiatric evaluation and inpatient treatment on 4/16/2025. All interactions between cognitively impaired residents are being monitored. Element #3: Lobby/common area supervision increased during peak resident usage hours. Behavioral Care Plans reviewed for all residents with cognitive impairment and aggression history. Staff re-educated all staff, including nursing, activities, and ancillary services, on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025 and monitoring of resident interactions. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to Abuse coordinator. Reception staff received 1:1 education on mandatory reporting. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.
Removal Plan
- The DON and designee(s) interviewed/assessed residents with BIMS scores of 8 and above for potential abuse. Residents with BIMS below 8 were assessed by a licensed nurse for an acute change in condition. Concerns were/were not identified.
- Social Services completed a supportive visit with R800.
- LPN E was suspended pending investigation and has not returned to the facility.
- The Abuse, Neglect and Exploitation policy was reviewed by the Administrator and deemed appropriate.
- The Administrator/designee re-educated all staff on the Abuse, Neglect and Exploitation policy, highlighting the requirement to notify the Abuse Coordinator (Administrator) immediately with all abuse allegations. No staff member will be permitted to work until re-education is received.
- The facility Medical Director was notified of this event.
- Facility IDT Team held an ADHOC QAPI meeting.
- From the abuse policy all staff were educated on: Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; Providing emotional support and counseling.
- CENA that left the room was provided 1:1 education regarding not to leave resident alone with abuser and the LPN assigned to the resident was provided 1:1 education to immediately report allegations of abuse and remove abuser as well and the educations received will be added to both their employee files.
- Facility IDT Team conducted an audit on all residents for their Safety/Abuse. Any negative findings will be immediately corrected.
- All findings will be taken to QAPI to follow up/track for any systematic changes that may be needed.
Failure to Honor DPOA and Arrange Post-Discharge Care
Penalty
Summary
The facility failed to honor the rights of a resident with severe cognitive impairment by not notifying or obtaining consent from the legally appointed Durable Power of Attorney (DPOA) prior to discharging the resident. The resident, who had diagnoses including cervical disc disorder, type 2 diabetes mellitus, and prostate carcinoma, was assessed with a Brief Interview for Mental Status (BIMS) score of 6/15, indicating severe cognitive impairment. The resident required substantial to maximal assistance with activities of daily living and was frequently incontinent. Despite the presence of legal documents designating a stepson as the DPOA and Patient Advocate, the facility discharged the resident to an estranged family member who was not listed in the contact records. On the day of discharge, the facility released the resident to the birth son, who presented a birth certificate as proof of relationship, and whose identity was confirmed over the phone by the resident's ex-wife. The DPOA was not contacted for consent, and the facility staff did not verify the ex-wife's identity. The Social Services Director and DON made the decision to release the resident without arranging for home care, physician follow-up, pharmacy, durable medical equipment, or hospice services. The facility's records indicated that attempts to contact the DPOA were made, but when there was no response, the discharge proceeded without further effort to obtain proper authorization. The facility staff maintained that the resident was their own responsible party and had not experienced a change in cognition, despite documentation of severe cognitive impairment and the existence of a signed DPOA and Patient Advocate form. The discharge was executed without honoring the legal authority of the DPOA, and no arrangements were made for the resident's continued care after leaving the facility.
Plan Of Correction
Element #1 Although R504 is no longer a resident, the facility made post-discharge contact with the legally designated DPOA (Stepson) & the resident is at home with no ill effects related to this occurrence. Re-education was immediately provided to all Social Services and Nursing leadership on interpreting and honoring DPOA and Patient Advocate documentation. Element #2 The facility conducted a comprehensive review of all current residents with a designated Durable Power of Attorney (DPOA) or Patient Advocate. This audit was completed by the Social Services Director and the Interdisciplinary Team. No additional instances of failure to honor a resident's DPOA or Patient Advocate authority were identified. Element #3 Policies regarding resident rights, discharge procedures, and DPOA/legal representative documentation have been reviewed and deemed appropriate. The Social Services Director completed a facility-wide audit of all residents with a listed DPOA or Patient Advocate to ensure documentation is accurate, activated properly, and reflected in the medical record. The IDT was re-educated on the role and authority of a DPOA/Patient Advocate. Legal definitions and proper activation (based on cognitive assessment and advance directive terms). Proper documentation and communication procedures. Audits will be repeated monthly for the next three months, then quarterly thereafter. Element #4 Ongoing Monitoring and QAPI Review: The DON and Administrator will review all discharges weekly during clinical stand-up to verify compliance with discharge and legal representative requirements. The QAPI committee will review audit results monthly and ensure any issues are corrected with retraining and process reinforcement. The Facility Administrator will be responsible for maintaining compliance.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident was inappropriately touched by another resident in the dining room without staff supervision. The incident was witnessed by the Activities Director, who observed one resident touching another's breast. At the time, there were three to four residents present in the dining room, but no staff were supervising. The Activities Director intervened immediately upon witnessing the event. Prior to the incident, staff had discussed the resident who committed the inappropriate act as having exhibited sexual behaviors, and some staff had warned others to be cautious when providing care to this resident. However, no formal reports of inappropriate or sexual behavior had been made to the Director of Nursing before the incident. The resident who was touched had a history of cognitive impairment, with a BIMS score indicating moderate impairment, and required assistance with activities of daily living, including bowel and bladder incontinence. The resident who committed the act also had significant physical and cognitive care needs, including hemiplegia, reduced mobility, and incontinence. The lack of staff supervision in the dining room allowed the incident to occur, despite prior informal awareness among staff of the perpetrator's inappropriate behaviors.
Plan Of Correction
Element #1 On March 3, 2025, immediately following the incident, the Activities Director separated residents R504 and R505 and reported the incident to the facility's Abuse Coordinator and Administrator in accordance with the facility's abuse policy. A full investigation was initiated within the required timeframe, including interviews with involved staff and residents, and findings were documented per regulation. Resident R504 was assessed for physical and emotional well-being by nursing and social services and monitored closely for psychosocial distress. Resident R505's care plan was immediately updated to reflect the behavior, with interventions including 1:1 supervision during group activities, increased monitoring, and review of the need for behavioral health support. R505 was moved to a different unit with staff trained to supervise higher-risk behaviors and reduce the risk of future interactions with R504. Element #2 The facility conducted a full audit of all residents with a known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3 Revised supervision in the dining room from the Activities department was implemented requiring an increased presence in dining/activity rooms when residents are present. No additional cases of resident-to-resident inappropriate behavior were identified during the audit. All staff, including nursing, activities, and ancillary services, were re-educated on the Abuse Policy and procedures, how to identify and document inappropriate behaviors, immediate response steps to peer-to-peer abuse, and enhanced supervision strategies. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4 The Director of Nursing or designee will conduct weekly rounds for four weeks then once a month for three months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.
Facility Fails to Maintain Clean and Repaired Environment
Penalty
Summary
The facility failed to maintain a clean and repaired environment, affecting all 126 residents. Observations revealed various issues, including debris buildup in shower drains, rusted and damaged heater registers, and soiled and improperly fitted bedding. Additionally, there were significant damages to walls, such as dents and holes, and widespread marring and scratches on resident room furniture. Flooring throughout the facility was dull and discolored, with significant soil buildup at room entry thresholds and door jambs. Further observations noted consistent issues across the facility's three resident wings. The flooring in resident rooms appeared dull and discolored, with greater discoloration at room entries. Door thresholds and jambs had significant soil buildup, and handrails in hallways were scratched and worn. The main transition hallway had worn paint, cracked tiles, and crumbling sheetrock. Additional issues included broken tiles, peeling wallpaper, and rusted door jambs and exit doors. Interviews with the Administrator, DON, and Maintenance Director revealed concerns about the building's condition. The Maintenance Director reported being the sole maintenance staff for most of the year, focusing on urgent tasks like unclogging toilets. A layoff of housekeeping, floor care, and maintenance staff the previous year had left the facility understaffed until September 2024. Although a process to address the environmental conditions had been initiated, a formal written plan or quality assurance project had not been completed.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding abnormal blood glucose levels for a resident with diabetes and a history of stroke with paralysis. The resident had a sliding scale insulin order that required physician notification for blood glucose levels greater than 450 mg/dl. On a specific day, the resident's blood glucose levels were recorded as 450 mg/dl at 9:56 AM, 550 mg/dl at 11:57 AM, and 550 mg/dl at 3:53 PM, all documented by an LPN. However, there was no notification to the physician for the abnormal glucose levels at 9:56 AM and 11:57 AM. It was only after the resident became lethargic with an unreadable blood sugar and an oxygen saturation of 66% that the physician was notified, and the resident was sent to the hospital. The facility's policy required notifying the physician for blood sugar readings over 400 mg/dl or the threshold established by the physician. Despite this, the LPN did not contact the physician after the initial high readings, and the Director of Nursing indicated that nurses should use their judgment to notify providers. The physician was unaware of the earlier high glucose readings and questioned the rapid elevation of the resident's blood sugar, which was over 1200 mg/dl at the hospital. The facility's failure to follow its policy for timely physician notification contributed to the resident's condition worsening and subsequent hospitalization.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement a care plan for two residents, leading to a deficiency in meeting their care needs. Resident R700, who has diagnoses including paraplegia, opioid independence, major depressive disorder, and anxiety disorder, expressed concerns about the care of their indwelling catheter. Despite having intact cognition as indicated by a Brief Interview for Mental Status assessment score of 15, there was no care plan with goals or interventions for the catheter care in R700's medical record. Similarly, Resident R701, diagnosed with encephalopathy, atherosclerotic heart disease, hemiplegia, and schizophrenia, reported recurring teeth pain. R701 also had intact cognition with a Brief Interview for Mental Status assessment score of 14. However, their medical record lacked an oral or dental care plan with goals and interventions for managing their pain. The Director of Nursing confirmed that each resident should have care plans addressing their specific needs, as per the facility's policy on care planning.
Facility Fails to Address Potential Asbestos in Basement Tiles
Penalty
Summary
The facility failed to maintain a safe and functional environment for its 133 residents, as evidenced by broken and missing floor tiles in the basement. During an observation, the Maintenance/Housekeeping/Laundry Director initially stated that the tiles contained asbestos and that corporate had instructed not to touch them. However, upon further questioning, the Director admitted uncertainty about the presence of asbestos, attributing the assumption to the appearance and size of the tiles. The Director also revealed that corporate was not informed about the tile issue but promised to report it. The Nursing Home Administrator was unaware of the potential asbestos in the floor tiles. Additionally, the facility failed to provide an environmental policy addressing floor tiles by the end of the survey.
Failure to Maintain a Homelike Environment Due to Linen Shortage
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, identified as R803, who was observed lying in bed with a worn, see-through gown and a stained pillowcase. The resident reported not having their bed linen changed since moving to a new room and mentioned a lack of linen at the facility. Observations of the resident's bathroom revealed water dripping from the toilet onto the floor, mold along the wall crease, and a thick layer of dust and debris on the bathroom vent. Additionally, linen closets were found to be lacking essential items such as towels, washcloths, fitted sheets, and gowns. The facility's laundry operations were compromised, with only one of two washers and two of three dryers functioning. The laundry aide reported a significant shortage of linen, with minimal supplies available in the laundry room. The Maintenance/Housekeeping/Laundry Director was unaware of the bathroom issues and acknowledged the need to restock linen due to staff requests. The Director of Nursing attributed the linen shortage to cuts in housekeeping, laundry, and maintenance departments. The Nursing Home Administrator mentioned purchasing a larger washer that could not fit into the building and ongoing education regarding linen storage. The facility's policy on handling clean linen did not specify restocking frequency or ensure sufficient linen availability for residents.
Failure to Maintain Accurate Medical Records and Shower Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six residents. Specifically, a nurse documented administering 13 medications to a resident who was on a leave of absence from the facility. Additionally, there was a lack of documentation for showers for seven residents over a 14-day period. The Director of Nursing was unaware of the medication documentation error and indicated that shower documentation should be recorded in the twice-weekly Skin Sweep Assessment by the nurse, based on shower sheets provided by CNAs. Interviews with residents revealed discrepancies between their reported care and the documented records. One resident reported receiving a shower on a specific date, while another stated they did not receive any showers or bed baths despite documentation indicating daily showers. Another resident expressed a preference for showers over bed baths, which was not reflected in the records. The MDS assessments indicated varying levels of cognitive function among the residents, with some having intact cognition and others being moderately impaired.
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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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