Harold And Grace Upjohn Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalamazoo, Michigan.
- Location
- 2400 Portage St, Kalamazoo, Michigan 49001
- CMS Provider Number
- 235050
- Inspections on file
- 28
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harold And Grace Upjohn Community Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment experienced a fall resulting in a head injury and was transferred to the hospital, but the family was not notified of the incident or transfer until the resident was being discharged from the hospital, contrary to facility policy requiring timely notification of emergency contacts.
A resident with multiple comorbidities developed stage II pressure ulcers that were not consistently documented or addressed in care plans. Staff interviews revealed confusion about the presence and staging of the wounds, and wound logs were incomplete or missing key information. Facility policies for wound assessment and documentation were not followed, leading to inadequate monitoring and care for the resident's pressure ulcers.
A resident's medical record lacked complete and accurate documentation of ADL care, with only half of the required showers or bed baths recorded and no evidence to support late entries made after family concerns were raised. The facility was unable to verify whether the resident received or refused care as required by policy.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment posed risks, and supervision protocols were not sufficient to ensure resident safety.
Construction equipment, materials, and resident room furniture were stored in a main corridor and adjacent open spaces during ongoing room renovations, obstructing exit access. The construction area was not separated from the corridor, and glue vapors were present, indicating poor ventilation. Some rooms in the affected corridor remained occupied by residents not under renovation.
The facility failed to comply with food safety standards, as observed during a survey. Improper cooling and storage of food items were noted, with chicken and rice not logged for cooling, and several items improperly dated or expired. Cleanliness issues were found with food contact surfaces, including debris on scoops and dispensers. Additionally, ice coolers did not allow for proper drainage, violating FDA guidelines.
Several residents experienced long wait times for call light responses, affecting their dignity and well-being. A resident with diabetes waited nearly an hour for assistance after a bowel movement, while another with an overactive bladder felt neglected due to frequent delays. A resident with dementia waited 45 minutes for a response, and a resident with a urinary catheter had a bleeding wound unattended for over an hour. The facility lacked evidence of recent staff education on call light response times.
An LPN at the facility repeatedly left her medication cart unattended with the computer screen open, displaying sensitive resident information, including that of a resident with type 2 diabetes. This occurred multiple times, with the LPN away for 5 to 10 minutes, allowing staff and others to view the exposed information. The LPN acknowledged knowing the requirement to lock the screen but admitted to forgetting.
A resident with a history of falls and a recent femur fracture experienced a fall, resulting in abrasions and bruises. The facility failed to adequately assess and document the resident's knee wounds, leading to a delay in treatment. Despite bleeding through bandages, the knee injuries were not addressed promptly due to their omission in the post-fall documentation. Interviews revealed a lack of adherence to expected assessment protocols by the nursing staff.
A resident with type 1 diabetes and moderate cognitive impairment did not receive necessary vision services due to a failure in scheduling an optometrist appointment. Despite an order from the Medical Director and documentation of broken glasses, the Medical Records Assistant was unaware of the need for an appointment, and the Unit Manager missed the progress note. As a result, the resident's vision needs were unmet, impacting their ability to perform daily tasks.
A resident with a Foley catheter experienced repeated UTIs due to the facility's failure to change the catheter as ordered. The resident, with a history of obstructive and reflux uropathy and neurogenic bladder, had an order for catheter change that was not completed, leading to continued infections. Observations showed improper catheter management, and staff interviews revealed a lack of awareness and communication about the order, resulting in additional UTIs.
A resident with multiple diagnoses experienced a delay in physician response to a pharmacist's medication regimen review recommendations. The recommendations included insulin dosage adjustments, discontinuation of montelukast, reevaluation of Miralax dosages, and reduction of Doxepin Hydrochloride. The physician's response was delayed by over a month, contrary to the facility's policy requiring timely action on such recommendations.
Two residents, both legally blind, were not provided with necessary adaptive dining equipment while in isolation, leading to difficulties in eating and drinking. The facility's policy of using disposable items during isolation conflicted with the residents' care plans, causing frustration and decreased independence.
The facility failed to ensure the Medical Director attended QAPI meetings quarterly, as required. The interim NHA reported a change to quarterly meetings with ad hoc sessions as needed. While the Medical Director attended some meetings, they missed the November session, and the sign-in sheet for that meeting was missing. This led to the potential for the Medical Director to be unaware of quality deficiencies.
The facility failed to follow infection control protocols for residents under transmission-based and enhanced barrier precautions. Staff did not use appropriate PPE for droplet precautions, and gowns were not worn during high-contact care for a resident at risk of spreading MDROs. Additionally, improper hand hygiene and glove use were observed during catheter care for a resident with an indwelling catheter.
A facility failed to obtain and document COVID-19 vaccination consent or declination for a resident with severe cognitive impairment, resulting in the resident's family not being informed about the vaccination and its risks and benefits. The resident's immunization record did not list the COVID-19 vaccine, and there was no documentation of communication with the resident's guardian. The facility's policy requires such documentation, which was not followed.
The facility failed to follow infection control protocols for two residents, leading to potential infection spread. A resident with dementia did not receive care under enhanced barrier precautions, and another resident on contact isolation for a UTI was exposed to staff not wearing PPE. Additionally, the facility did not notify staff and visitors of confirmed COVID-19 cases, resulting in improper mask usage and lack of signage on the affected unit.
The facility failed to maintain an agreement with the dialysis provider for four residents requiring dialysis services, leading to potential disruptions in care. Despite efforts to locate the agreement, it was not found, impacting residents with serious health conditions.
The facility failed to implement proper infection control protocols, including Enhanced Barrier Precautions (EBP), for residents with indwelling medical devices. Observations and staff interviews revealed a lack of appropriate signage and PPE, and the EBP program had not been initiated. Additionally, infection control policies had not been reviewed or updated annually, leading to outdated practices.
The facility failed to ensure timely care and services during meal times for three residents, leading to long call light wait times, incontinence, and meals left unattended. These deficiencies resulted in feelings of frustration, embarrassment, and diminished self-worth among the residents.
A resident with multiple health conditions reported only receiving a shower once a week despite preferring baths to help with body pain. Interviews with CNAs revealed that while they generally asked residents about their bathing preferences, this resident's preference for a bath was not accommodated, resulting in the resident not achieving his highest practicable level of well-being.
The facility failed to provide a written transfer notice for a resident who was hospitalized. The resident and his daughter did not receive any notice before the transfer, and staff interviews revealed a lack of awareness and training regarding the requirement to provide such a notice. The facility was unable to provide documentation of a written transfer notice by the time of the survey exit.
A resident with Type 2 diabetes, bipolar disorder, and insomnia was transferred to a hospital without receiving a written bed hold policy. The facility staff confirmed that the policy was undated, unsigned, and not properly documented. Interviews revealed that the policy should be completed and signed before transfer, but this procedure was not followed.
The facility failed to accurately complete MDS assessments for two residents, resulting in an inaccurate reflection of their health status. One resident's PTSD diagnosis was not recorded, and another resident's injury was incorrectly documented as a Stage 2 pressure ulcer.
The facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including dementia and stroke. Observations revealed that specific interventions, such as keeping the bed in a low position and ensuring glasses were within reach, were not consistently followed. Interviews with staff indicated a lack of adherence to the care plan, resulting in inadequate service for the resident's well-being.
The facility failed to ensure residents received care according to professional standards, resulting in potential delays in treatment. One resident had a contaminated urine sample with no follow-up actions documented, while another resident was observed self-administering Biofreeze gel without a current order or assessment.
A facility failed to ensure timely review and response to a pharmacist's medication regimen review recommendations for a resident with a pulmonary artery embolus. The recommendations to discontinue diphenhydramine and low-dose aspirin were delayed by 17 days before being reviewed and declined by the nurse practitioner, due to a breakdown in the facility's process.
The facility failed to maintain a sanitary environment for a resident and shared medical equipment, leading to potential cross-contamination and infections. Observations revealed unsanitary conditions on broda chairs, a recliner seat, a hoyer lift machine, and other equipment. Staff interviews indicated inconsistencies in cleaning responsibilities and schedules, contrary to the facility's policy on cleaning and disinfection.
A resident with cognitive impairment and multiple diagnoses, including second-degree burns, experienced significant harm due to delayed treatment after spilling hot tea on her lap. The staff did not promptly apply cool liquid to the affected area, leading to additional skin breakdown, prolonged healing, infection requiring IV antibiotics, and ongoing pain. The incident highlights the importance of immediate intervention following a burn to prevent further complications.
The facility failed to ensure proper catheter tubing securement for a resident with severe cognitive impairment and multiple medical conditions, despite a physician's order. Observations revealed the absence of a securement device, leading to potential risks. Staff acknowledged the issue, citing unavailable devices and delays in ordering alternatives.
A resident with severe cognitive impairment and second-degree burns experienced significant pain during wound care due to the facility's failure to adhere to physician orders for applying lidocaine ointment 10-15 minutes prior to treatment. Staff did not consistently wait the required time, causing the resident distress during dressing changes.
Failure to Notify Family of Resident's Fall, Injury, and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's emergency contact following a series of emergency incidents involving a resident with severe cognitive impairment, including dementia, repeated falls, anxiety, and depression. The resident experienced a fall resulting in a head injury with bleeding, which required immediate transfer to an acute care hospital for evaluation and treatment. Although the physician was notified shortly after the incident, the resident's family was not informed of the fall, injury, or hospital transfer at the time these events occurred. Documentation and interviews revealed that the family only became aware of the incident when the resident was being discharged from the hospital, several hours after the initial event. The facility's policy required notification of the resident's representative in such situations, especially for residents incapable of making decisions. The lack of timely communication left the family unaware of the resident's condition and hospital transfer until after medical intervention had already taken place.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
A resident with a history of morbid obesity, edema, venous insufficiency, and hypothyroidism was found to have quarter-sized, healing stage II pressure ulcers on both buttocks during an observation. The resident reported having the ulcer for many months, and there was no pain or drainage noted at the time of observation. Despite the presence of these wounds, the resident's care plans did not address the risk for pressure ulcers or document a history of pressure ulcers. Physician orders for wound care were in place, but documentation in the medical record was inconsistent and incomplete, with missing weekly wound notes and lack of detailed wound assessments. Multiple staff interviews revealed confusion and lack of awareness regarding the resident's pressure ulcers. Some staff, including the nurse practitioner and LPNs, were unsure if the resident had a pressure ulcer, and there was disagreement about the staging and nature of the wounds. The wound log was incomplete, with missing measurements, staging, and inconsistent entries. The interdisciplinary team, including the registered dietitian and director of health and wellness, were unaware of the wound log and the resident's wound status. Additionally, there was no incident report or clear documentation of when the pressure ulcer was first identified, and weekly skin assessments were not consistently performed as required by facility policy. Facility policies required thorough documentation of skin assessments, regular wound monitoring, and interdisciplinary care planning for pressure ulcers. However, these procedures were not followed, as evidenced by the lack of detailed wound documentation, incomplete care plans, and inconsistent communication among staff. The failure to provide necessary care and services consistent with professional standards resulted in the potential for worsening or recurrence of pressure injuries for the resident.
Failure to Accurately Document Resident ADL Care
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record of a resident regarding activities of daily living (ADLs), specifically related to showers and bed baths. During the resident's stay, only 6 out of 12 possible showers or bed baths were documented, with records showing 4 completed and 2 refused. There was no documentation for the remaining 6 instances, making it unclear whether the resident received or refused care on those occasions. This lack of documentation was identified after concerns were raised by the resident's family member about whether the resident was receiving appropriate hygiene care and skin checks. Further review revealed a late entry progress note written by a nurse after a family meeting, stating that the resident received a bed bath on one date and refused care on another. However, there were no supporting shower sheets or other documentation to verify these claims. When questioned, the Nursing Home Administrator could not explain where the information in the late entry note originated, as it was not supported by existing records. The facility's own policy requires that documentation be completed at the time of service or by the end of the shift, but this standard was not met in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Obstructed Exit Access Corridors During Construction
Penalty
Summary
During an observation conducted between 12:00 PM and 1:00 PM, construction equipment, materials, and resident room furniture were found stored in the 100 corridor and in spaces open to that corridor, obstructing the exit access corridors. The construction room door was blocked open, and there was no separation between the construction work area and the corridor. Additionally, glue vapors were present in the corridor, indicating improper ventilation. At the time of the survey, a floor renovation was ongoing in residents' rooms, with some rooms still occupied by residents not under renovation. Construction materials were also stored in a resident day area open to the corridor.
Plan Of Correction
1. All exit access corridors were cleared of all obstructions, including construction equipment/materials and resident furniture, in accordance with LSC 19.2.2 and chapter 7. 2. Actively scheduled staff requiring education will be identified to receive education on keeping exit corridors clear of obstructions. 3. The Director of Plant Operations and/or designee will conduct a weekly audit, and results of the audits will be brought to the Quality Assurance Performance Improvement Committee monthly for review. Any changes to the auditing process will be made by the QA Committee. The Administrator is responsible for attaining and maintaining compliance. 4. The completion date for compliance will be 05/1/2025
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. In the walk-in cooler, a 3-gallon container of chicken breast and two single-gallon containers of rice and gravy were found with condensation and a temperature of 42F, indicating improper cooling. Staff interviews revealed that cooling logs were not maintained, and food was left out on the counter before being placed in the cooler. The facility's Kitchen Policy requires a Cooling Log for potentially hazardous food items, but this was not followed, violating the 2017 FDA Food Code's cooling requirements. Additional deficiencies were noted in the cleanliness and maintenance of food contact surfaces and equipment. Mechanical scoops were found with dried food debris, and the juice and pop dispensers had accumulations of debris. The microwave in the east Nourishment room also had food and dried debris. These observations contravene the FDA Food Code, which mandates that food-contact surfaces and equipment be clean to sight and touch, free of encrusted grease deposits, and other soil accumulations. The facility also failed to properly date and store food items. An open container of grape jelly was left unrefrigerated, and hard-boiled eggs were improperly dated. Nutritional shakes and thickened water were not dated, and several expired food items were found in various locations, including fruit cups and nutritional supplement puddings. The FDA Food Code requires that ready-to-eat, time/temperature control for safety food be clearly marked with a date for consumption or disposal. Additionally, ice coolers used in the facility did not allow for self-draining, leading to water mixing with ice, which is against FDA guidelines for storing food in contact with water or ice.
Delayed Call Light Responses Affect Resident Dignity
Penalty
Summary
The facility failed to respond timely to call lights, affecting the dignity and well-being of several residents. Resident #4, who has type 1 diabetes and moderate cognitive impairment, reported waiting almost an hour for assistance after a bowel movement, leading to frustration. Resident #10, with an overactive bladder and moderate cognitive impairment, also experienced long wait times, feeling neglected by the staff. Resident #22, cognitively intact, expressed frustration over frequent long wait times for call light responses. Resident #36, with dementia and moderate cognitive impairment, was observed waiting 45 minutes for a response to his call light, during which he became hungry and attempted to find assistance independently. Two staff members were noted at the nurses' desk during this time, but did not respond to the call light. Resident #237, cognitively intact, had a urinary catheter and was observed with a blood-soaked bandage on his forehead. Despite the call light being activated, it went unanswered for over an hour, during which the resident's family member expressed concerns about the resident's care. The facility's Unit Manager was aware of past concerns regarding call light response times and believed improvements had been made through staff education. However, the Nursing Home Administrator admitted that recent education on call light response times had not occurred. The facility was unable to provide maintenance orders or evidence of staff education on call light response times, indicating a lack of follow-through on addressing the issue.
LPN Leaves Computer Screen Unattended, Exposing Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of resident health information, specifically for Resident #71, as required by HIPAA regulations. During multiple observations on March 12, 2025, it was noted that an LPN repeatedly left her medication cart unattended with the computer screen open, displaying sensitive resident information. This occurred at various times throughout the morning and early afternoon, with the LPN leaving the cart for periods ranging from 5 to 10 minutes. During these times, the computer screen was visible to anyone passing by, including other staff members, compromising the privacy of the residents' medical information. Resident #71's medical information was specifically noted to be exposed during one of these instances, with several staff members walking past the open screen. The LPN admitted in an interview that she was aware of the requirement to lock the computer screen when not in attendance but stated that she sometimes forgets to do so. This repeated oversight led to a breach of confidentiality for Resident #71 and potentially other residents whose information was visible on the screen.
Inadequate Assessment and Delayed Treatment for Resident's Fall Injuries
Penalty
Summary
The facility failed to ensure adequate assessment and timely treatment for a resident, identified as R237, who experienced a fall resulting in abrasions. The resident, who was cognitively intact with a BIMS score of 13/15, had a history of falling and a recent fracture of the left femur. On the day of the incident, the resident was found on the floor after sliding off a wheelchair, sustaining a skin tear on the forehead and abrasions on both knees, along with bruises on the face, neck, and chest. Despite these injuries, the post-fall documentation did not include the knee wounds, leading to a delay in treatment. Observations revealed that the resident's knee wounds were bleeding through the bandages, staining the sheets and blanket with blood. The RN initially assessed and changed the bandage on the resident's head but did not address the knee wounds due to their absence in the post-fall documentation. Interviews with the Director of Nursing and Unit Manager highlighted expectations for thorough fall assessments, which were not met in this case. The CNA who found the resident confirmed the presence of scrapes on the knees and a bleeding head wound, indicating a lack of comprehensive assessment and documentation by the nursing staff.
Failure to Provide Vision Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities, resulting in the resident's inability to attain or maintain the highest practicable level of well-being. Resident #4, who was moderately cognitively impaired and had type 1 diabetes, had a care plan intervention to arrange a consultation with an eye care practitioner due to impaired visual function. An order was placed by the Medical Director for Resident #4 to consult a visiting optometrist because of low vision and a clouded magnifier on his glasses, but this order did not have a completion date and was not acted upon. Despite the resident's broken glasses being documented in progress notes, the Medical Records Assistant did not schedule an appointment as she was unaware of the order. The Unit Manager, who typically reviews progress notes daily, missed the note about the broken glasses and was unaware of the need for an optometrist consultation. Consequently, Resident #4 did not see an eye doctor and had no appointment scheduled, despite the Medical Director's order and the resident's expressed difficulty in completing daily tasks due to the broken glasses.
Failure in Catheter Care Leads to Repeated UTIs
Penalty
Summary
The facility failed to provide proper coordination of care and services for a resident with a Foley catheter, leading to repeated urinary tract infections (UTIs). The resident, who was admitted with obstructive and reflux uropathy and had a neurogenic bladder, had an order for the catheter to be changed after 48 hours due to a UTI. However, this order was not completed, and the resident continued to experience UTIs. Observations revealed that the catheter bag was improperly placed on the floor, and there was heavy sediment in the tubing, indicating poor catheter management. Interviews with facility staff, including the Unit Manager, Assistant Director of Nursing, and Hospice Nurse, revealed a lack of awareness and communication regarding the catheter change order. The Medical Director confirmed placing the order, but it was not executed due to incorrect order entry and lack of follow-up. This oversight resulted in the resident experiencing additional UTIs, highlighting a significant deficiency in catheter care and communication within the facility.
Delayed Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely physician review and response to a licensed pharmacist's monthly medication regimen review recommendations for a resident. The resident, a male with diagnoses including diabetes, insomnia, anxiety, and depression, was subject to several medication regimen recommendations that were not addressed promptly. These recommendations included adjustments to insulin dosages, discontinuation of montelukast due to potential neuropsychiatric side effects, reevaluation of Miralax dosages, and reduction of Doxepin Hydrochloride due to risks associated with its use in older adults. The physician did not respond to these recommendations until more than a month later, with some responses delayed by over two months. The Director of Nursing reported that pharmacy consultation reports should be reviewed by the physician to agree or disagree with the recommendations, and necessary orders should be placed based on these recommendations. The facility's policy on Medication Regimen Review requires that any irregularities identified by the pharmacist be communicated in writing within 10 working days, and facility staff are expected to act upon these recommendations. However, in this case, the physician's delayed response to the pharmacist's recommendations resulted in a failure to address potential medication interactions and adverse side effects in a timely manner.
Failure to Provide Adaptive Dining Equipment During Isolation
Penalty
Summary
The facility failed to provide adaptive dining equipment to two residents, both of whom were legally blind and required such equipment to eat and drink independently. Resident #3, who was on droplet precautions due to suspected influenza, did not receive a dual-handled cup and scoop plate as specified in her care plan. Instead, she was given a can of cola and a disposable foam container, which did not meet her needs. The CNA confirmed the absence of the required adaptive equipment, and the LPN explained that the facility's policy was not to provide such equipment to residents on transmission-based precautions. Resident #4, who was moderately cognitively impaired and also legally blind, was similarly affected. His care plan required the use of adaptive silverware and bowls to assist with his visual deficits. However, while in isolation, he was not provided with these items and struggled to eat using plastic utensils and styrofoam containers. The resident expressed frustration over the situation, and the Occupational Therapist confirmed that the adaptive equipment was necessary for his self-feeding. The facility's policy during isolation was to use disposable dining items to prevent infection spread, as stated by the Dining Services Manager and the Infection Preventionist. However, the Infection Preventionist also noted that adaptive equipment should be sent with a plastic bag for cleaning after use. The CDC guidelines referenced in the report indicate that no special precautions are needed for dishware and eating utensils, suggesting that the facility's policy may not align with these guidelines.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director was a mandatory attendee at the Quality Assessment and Process Improvement (QAPI) meetings at least quarterly. During an interview, the interim Nursing Home Administrator (NHA) reported that the facility had recently changed their QAPI meetings to a quarterly schedule with additional ad hoc meetings as needed. Although the Medical Director attended an ad hoc meeting in March 2025, the NHA could not initially provide documentation of the Medical Director's attendance at the quarterly meetings over the past year. Upon further review, it was confirmed that the Medical Director attended meetings in July and August 2024, and February 2025, but did not attend the November 2024 meeting. Instead, a Nurse Practitioner attended the November meeting, but the sign-in sheet for this meeting was not located. This deficiency resulted in the potential for the Medical Director to be unaware of quality deficiencies occurring in the facility.
Infection Control Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control practices, as evidenced by multiple observations involving residents under transmission-based precautions and enhanced barrier precautions. For Resident #27, a hospice registered nurse entered the room, which was under droplet precautions, wearing only a surgical mask without the required eye protection. Additionally, a hospice aide entered the same room wearing personal eyeglasses instead of approved eye protection. The facility's infection control policy and CDC guidelines were not followed, as both staff members failed to don the necessary personal protective equipment (PPE) for droplet precautions. Resident #38 was under enhanced barrier precautions due to the risk of spreading multidrug-resistant organisms (MDROs). Despite the requirement for staff to wear gowns and gloves during high-contact care activities, certified nursing assistants and a registered nurse were observed providing care without gowns. This included bed mobility and brief changes, during which the staff's clothing came into contact with the resident's bed linens. The infection preventionist confirmed that gowns and gloves were required for any high-contact resident care, contradicting the staff's understanding and practice. For Resident #42, who had an indwelling catheter, the facility failed to maintain proper infection control during catheter care. A registered nurse was observed placing supplies on a visibly soiled tray table and administering medications without washing hands or changing gloves. The nurse also failed to change gloves or wash hands before handling the catheter and the resident's genital area. The infection preventionist acknowledged that no recent catheter care education or audits had been conducted, and emphasized the expectation for nurses to wash hands and change gloves when necessary during care.
Failure to Document COVID-19 Vaccination Consent for a Resident
Penalty
Summary
The facility failed to obtain COVID-19 vaccination consents or declinations for a resident, identified as Resident #71, who was reviewed for immunizations. This deficiency resulted in the resident's family members not being informed about the vaccination and the associated risks and benefits. Resident #71 was admitted to the facility with diagnoses including type 2 diabetes and had undergone surgery of the digestive system. The resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and had a guardian due to this cognitive status. The review of Resident #71's immunization record showed that the COVID-19 vaccine was not listed, making it unclear whether the resident received or refused the vaccine. The facility's COVID Vaccine Resident List indicated a refusal, but there was no documentation that the resident's guardian was contacted for consent or declination, nor was there evidence of education provided on the vaccine's risks and benefits. During an interview, the Assistant Director of Nursing, who also served as the Infection Preventionist, confirmed the absence of documentation regarding the consent or declination and the lack of communication with the guardian. The facility's COVID-19 Vaccination Policy requires education and documentation of consent or declination, which was not adhered to in this case.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to enhanced barrier and contact precautions for two residents, leading to potential transmission of infections. Resident #104, diagnosed with dementia, had orders for enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs). However, during an observation, a registered nurse (RN) was seen administering care without wearing the required gown, despite acknowledging the necessity of such precautions. The RN admitted to not following the protocol due to being busy, which increased the risk of spreading MDROs. Resident #105, with a diagnosis of heart failure, was on contact isolation for a urinary tract infection caused by Enterococcus. Despite clear signage indicating the need for gloves and gowns before room entry, multiple staff members, including a life enrichment aide and a certified nursing assistant, entered the room without the necessary protective equipment. The staff members either were unaware of the contact precautions or chose not to follow them, further risking the spread of infection. Additionally, the facility failed to notify staff and visitors of confirmed COVID-19 infections within the facility. Observations revealed that staff on the affected unit were not consistently wearing masks, and there was a lack of signage indicating the presence of COVID-19 and the required precautions. Interviews with staff, including the infection preventionist, revealed a lack of communication and enforcement of infection control measures, contributing to the potential spread of COVID-19 within the facility.
Failure to Maintain Dialysis Service Agreement
Penalty
Summary
The facility failed to ensure that an agreement between themselves and the dialysis provider was established and maintained for four residents requiring dialysis services. This deficiency was identified during interviews and record reviews, revealing that the facility could not provide a contract or agreement with the dialysis provider. The lack of such an agreement resulted in the potential for disruption in the continuity of care and interruption of dialysis treatments for the affected residents. Resident #61, a male with diagnoses including stroke, dialysis, dementia, and diabetes, was one of the residents affected. Similarly, Resident #28, a female with conditions such as stroke, heart failure, and end-stage renal disease, also required dialysis services. Resident #20, a male with acute kidney failure, heart failure, and dependence on renal dialysis, and Resident #75, a female with heart failure, renal insufficiency, and dependence on renal dialysis, were also impacted. Despite efforts by the Nursing Home Administrator to locate the agreement, it was not found, and no contact was made with the dialysis provider before the survey exit.
Failure to Implement Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to implement proper infection control protocols and practices, including Enhanced Barrier Precautions (EBP) per national standards of practice for eight residents reviewed for infection control. Observations revealed that residents with indwelling medical devices, such as catheters and PICC lines, did not have appropriate signage or personal protective equipment (PPE) available. Staff interviews confirmed that EBP was not being utilized, and the Infection Preventionist reported that the EBP program had not yet been initiated, pending upper management approval. This lack of implementation was observed in multiple instances, including residents with catheters and wounds, where staff only used gloves and did not don additional PPE as required by EBP guidelines. Additionally, the facility failed to ensure that infection control policies were reviewed and updated on an annual basis. The review of facility policies, such as the Antibiotic Stewardship, Influenza Vaccination, and COVID-19 Vaccination policies, revealed that they had not been updated for several years. Interviews with the Infection Preventionist and the Nursing Home Administrator confirmed that the policies were outdated and in the process of being revamped. The lack of timely review and update of these policies could result in the facility not adhering to current standards of practice for infection control. Specific instances of non-compliance included residents with diagnoses such as benign prostatic hyperplasia, osteomyelitis, dementia, and neurogenic bladder, who had indwelling medical devices but no EBP signage or PPE available. Staff members, including Certified Nursing Assistants and Licensed Practical Nurses, were observed providing care without the required PPE. Interviews with staff indicated a lack of awareness or implementation of EBP, further highlighting the facility's failure to adhere to infection control protocols. This deficiency increased the potential for the spread of infection, cross-contamination, and disease transmission among residents in the facility.
Failure to Ensure Timely Care and Dignified Environment During Meal Times
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity and ensure a dignified environment during meal times for three residents. Resident #10, who was cognitively intact, reported long call light wait times, sometimes up to an hour, resulting in bowel incontinence. This made her feel diminished and as though she was nothing. Resident #331, who was mildly cognitively impaired, experienced a similar issue. Her family member reported a 20-minute wait for assistance, leading to an incontinent episode of stool, causing the resident to feel angry and embarrassed. Observations confirmed that call lights were often left unanswered due to staff shortages and technical issues with the call light notification system, which did not always work properly on the mobile phones carried by CNAs. Additionally, the display screen for call light notifications was not visible to staff when they were away from the nurses' station, further delaying response times. The Director of Nursing and other staff acknowledged these issues, noting that the system was unreliable and that CNAs often did not use the phones as intended. Resident #6, who had multiple diagnoses including dementia and required assistance with meals, was observed lying in bed with his lunch tray left unattended for over 15 minutes. This delay in assistance was confirmed by staff interviews, which revealed that residents needing help with meals received their trays last, and the assigned CNA was responsible for providing the necessary assistance. The Quality Improvement Coordinator confirmed that meal trays for residents requiring assistance should not be left in the room without immediate help. These deficiencies in timely care and assistance during meal times led to feelings of frustration, embarrassment, and diminished self-worth among the residents involved.
Failure to Honor Resident's Bathing Preference
Penalty
Summary
The facility failed to accommodate a resident's right to make choices consistent with their assessment and plan of care. Resident #61, a male with diagnoses including stroke, dialysis, dementia, anxiety, peripheral vascular disease, aphasia, apraxia, diabetes, and high blood pressure, reported that he only received a shower once a week and preferred to take a bath to help with his body pain. Despite the facility having two bathtubs available, Resident #61 was not offered a bath, which he expressed a preference for during an interview. His family member also confirmed his preference for baths over showers. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that while they generally asked residents about their bathing preferences, Resident #61's preference for a bath was not accommodated. The CNAs reported that they usually followed the residents' preferences and documented them in the kardex, but in this case, Resident #61's preference for a bath was overlooked. This failure resulted in the resident not achieving his highest practicable level of well-being, as his preference for a bath to alleviate body pain was not honored.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer for Resident #15, who was hospitalized. Resident #15, who had diagnoses including Type 2 diabetes mellitus, bipolar disorder, and insomnia, was cognitively intact with a BIMS score of 15/15. On the day of the transfer, the resident was sent to a hospital without receiving a written notice of transfer. The resident and his daughter reported that they did not receive any notice before the transfer. Interviews with various staff members, including the Manager of Case Management, Registered Nurses, and the Director of Nursing, revealed that the standard paperwork for a transfer did not include a transfer notice. Additionally, the Medical Records Assistant confirmed that there was no transfer notice in the resident's electronic medical record for the transfer date in question. The staff interviews indicated a lack of awareness and training regarding the requirement to provide a written transfer notice. One RN specifically mentioned that she had never been informed about the need to send a transfer notice and did not know what it was. The facility was unable to provide documentation of a written transfer notice for Resident #15 by the time of the survey exit, highlighting a systemic issue in the facility's transfer procedures and communication protocols.
Failure to Provide Written Bed Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to a resident and their representative during a transfer to a hospital. Resident #15, who had diagnoses including Type 2 diabetes mellitus, bipolar disorder, and insomnia, was transferred to a hospital without receiving a written bed hold policy. The resident, who was cognitively intact with a BIMS score of 15/15, reported that neither he nor his daughter received the bed hold policy before the transfer. The facility staff, including the Manager of Case Management and the Medical Records Assistant, confirmed that the bed hold policy was undated, unsigned, and not properly documented in the resident's medical record. Interviews with the Director of Nursing and a Registered Nurse revealed that the bed hold policy should be completed and signed by the resident before transfer, but this procedure was not followed. The facility's policy required that the bed hold policy be provided in writing at the time of transfer, specifying the duration and return process. However, the staff were unable to provide documentation of a written bed hold policy for Resident #15's transfer, leading to the deficiency noted in the survey.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents, resulting in an inaccurate reflection of their health status. For Resident #41, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), the MDS assessment did not indicate the presence of PTSD. The MDS Coordinator (MDSC) acknowledged that the PTSD diagnosis should have been checked but was not, due to an error in the electronic medical record system. The MDSC admitted that not every diagnosis was reviewed for accuracy before submission to CMS, leading to the oversight. For Resident #43, the MDS assessment inaccurately documented a Stage 2 pressure ulcer. The resident had an open area on the right ankle caused by repeatedly hitting the ankle on the wheelchair, which was not a pressure ulcer. The Assistant Director of Nursing (ADON) confirmed that the wound was not a pressure ulcer, and the MDSC admitted to mistakenly coding it as such. Both MDS assessments were acknowledged as inaccurate and required correction and resubmission.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident #6, who had multiple pertinent diagnoses including dementia, stroke, muscle weakness, dysphagia, pigmentary retinal dystrophy, repeated falls, anxiety, and monoplegia. The care plan, revised on 7/19/22, included specific interventions such as keeping the bed in a low position, ensuring glasses were within reach, and using hipsters and blue wedges for fall prevention. However, multiple observations revealed that these interventions were not consistently implemented. For instance, the resident's bed was not in a low position, glasses were out of reach, and blue wedges and hipsters were not in place as required by the care plan. Interviews with staff, including a CNA and the DON, indicated a lack of adherence to the care plan interventions. The CNA reported placing the call light by the resident's legs but did not ensure other interventions were in place. The DON relied on unit managers and staff to implement and monitor the care plan but acknowledged that the interventions were not consistently followed. This failure to implement the care plan resulted in a lack of service for Resident #6 to maintain his highest practicable physical, mental, and psychosocial well-being.
Deficiencies in Nursing Practice and Documentation
Penalty
Summary
The facility failed to ensure residents received care in accordance with professional standards of nursing practice for two residents. Resident #6, who had a history of recurrent urinary tract infections (UTIs), was found to have a contaminated urine sample. Despite the contamination, there was no documentation of follow-up actions or communication with the provider to obtain a new sample. The resident's medical record lacked documentation of the conversation between the provider and the nurse regarding the contaminated sample, and the resident continued to exhibit symptoms of a UTI without appropriate intervention or documentation of care provided. Resident #61 was observed self-administering Biofreeze gel without a current physician's order or an assessment to determine his ability to self-administer medications. The resident's medical record showed that previous orders for Biofreeze had been discontinued, and there was no documentation of a new order or assessment. Staff provided the Biofreeze to the resident without proper authorization, and the facility's Quality Improvement Coordinator confirmed that an order and assessment were required for self-administration of medications. These deficiencies highlight a lack of adherence to professional standards of nursing practice, including proper documentation, communication with healthcare providers, and ensuring that residents receive care according to physician orders. The failure to follow established protocols for urine sample collection and medication administration resulted in potential delays in treatment and inadequate care for the residents involved.
Failure to Timely Address Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure the attending physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations in a timely manner for one resident. Resident #41, who had a pertinent diagnosis of a saddle embolus of the pulmonary artery, had two pharmacist recommendations dated 05/06/2024. The first recommendation was to discontinue diphenhydramine due to its strong, sedating anticholinergic properties and to consider initiating PRN loratadine. The second recommendation was to discontinue low-dose aspirin due to the increased risk of serious, potentially fatal bleeding when used concomitantly with Eliquis. Both recommendations were not addressed until 05/23/2024, resulting in a delay of 17 days before the nurse practitioner reviewed and declined the recommendations, citing the need for diphenhydramine for rash with itching and the history of pulmonary embolism for the continued use of aspirin. The delay in addressing the pharmacist's recommendations was attributed to a breakdown in the facility's process. The Director of Nursing (DON) reported receiving the pharmacist's consultation reports on 05/08/2024 but failed to ensure they were promptly reviewed by the medical provider. The reports should have been printed and placed in the medical provider's mailbox for review, but this step was not completed in a timely manner. The Nursing Home Administrator (NHA) acknowledged the issue, indicating a need to review and address the process to prevent future delays.
Failure to Maintain Sanitary Conditions for Resident and Shared Medical Equipment
Penalty
Summary
The facility failed to ensure a sanitary environment for Resident #6 and the shared medical equipment, leading to potential cross-contamination and infections. During observations, a broda chair outside of room [ROOM NUMBER] was found with dried liquid, dirt, and debris on various parts, including the armrest, back pad, footrest, and seat cushion. Similar unsanitary conditions were noted on another broda chair and a recliner seat located between rooms [ROOM NUMBER] and 25, with dirt, debris, and dried material on different parts of the chairs. Additionally, a hoyer lift machine was observed with dried red spillage on the bottom frame, and a broda chair had significant dirt and grime around the wheels and casters. The fall mat and light blue wedges in Resident #6's room were also found to be soiled and in need of cleaning. Interviews with staff revealed inconsistencies in the cleaning responsibilities and schedules. Certified Nursing Assistant (CNA) Y reported that wheelchairs were cleaned during the night shift according to a schedule, while CNA JJ mentioned that housekeeping usually cleaned the fall mats, but she would clean them if something was spilled. Licensed Practical Nurse (LPN) E confirmed that wheelchairs and broda chairs were cleaned on the third shift and that it was everyone's responsibility to ensure the fall mats were cleaned. The Infection Preventionist (IP) H stated that shared equipment should be cleaned before and after each use. The facility's policy on Cleaning and Disinfection of Resident Care Equipment, approved on 05/08/2024, mandates that reusable resident-care equipment be cleaned and disinfected according to CDC recommendations to prevent the transmission of pathogens. The policy specifies that direct care staff are responsible for cleaning single-resident equipment when visibly soiled and according to a routine schedule. However, the observations and interviews indicate that these guidelines were not consistently followed, resulting in unsanitary conditions for Resident #6 and shared medical equipment.
Delayed Treatment of Hot Liquid Burn Resulting in Complications
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to immediately treat a hot liquid burn per professional standards of practice for a resident (Resident #103) who spilled a cup of hot liquid on her lap. Despite the incident occurring on 2/22/24, where Resident #103 spilled hot tea on her lap resulting in burns to both her legs and buttocks, the facility staff did not promptly apply cool liquid to the affected area to stop the burn process. This lack of immediate intervention led to additional skin breakdown, prolonged healing, infection requiring IV antibiotics, and ongoing pain for Resident #103. The report details how Resident #103, a female with pertinent diagnoses including second-degree burn of thigh, skin infection, stroke with left-sided weakness, peripheral vascular disease, dementia, and anxiety, experienced significant harm due to the delayed treatment of her burn. Despite Resident #103's severe cognitive impairment, the staff's response to the hot liquid spill was inadequate, as they only applied cream to the affected area without utilizing cool liquid to stop the burning process. This failure to adhere to professional standards of practice resulted in the development of blisters and extensive burns on Resident #103's thighs, leading to a cascade of complications requiring hospital evaluation, wound clinic treatment, IV antibiotics, and ongoing wound management. The deficiency was further highlighted by the accounts of family members, staff, and healthcare providers involved in Resident #103's care. Family members expressed distress over the staff's lack of knowledge on how to respond to the hot liquid spill, emphasizing Resident #103's ongoing pain and suffering as a result of the delayed treatment. Healthcare providers noted the severity of Resident #103's burns, the need for IV antibiotics, and the challenges in managing the wounds due to the delayed initial intervention.
Failure to Secure Catheter Tubing as Ordered
Penalty
Summary
The facility failed to ensure that catheter tubing was properly secured for a resident with an indwelling catheter, as per the physician's order. This deficiency was observed in a resident with severe cognitive impairment and multiple medical conditions, including second-degree burns, a skin infection, and stroke-related weakness. During multiple observations, it was noted that the resident's Foley catheter was not secured with a device to prevent pulling or tugging, which could lead to potential dislodgement and urethral damage. The catheter tubing was observed to be taut, and the securement device was missing on several occasions, despite a physician's order to change the securement device every Sunday night shift for trauma prevention. Staff interviews revealed that the securement device was not available on the unit, and a different style of device was ordered but not yet received. The facility placed an order for the securement devices only after the deficiency was noted by surveyors. The resident's medical records indicated that the Foley catheter was initially placed for wound management due to burns on the thighs and buttocks. Despite the physician's order and the resident's need for proper catheter care, the securement device was not consistently used. Staff members, including the Assistant Director of Nursing and Unit Manager, acknowledged the absence of the securement device and reported that the resident had previously complained about skin irritation from the strap-style device. However, no alternative securement device was provided in a timely manner, leading to the observed deficiency. The facility's failure to maintain proper catheter care as per the physician's order was documented in the Medication Administration Record and Health Status Notes, highlighting the lack of available securement devices and the delay in ordering a new style of device.
Failure to Implement Pain Management Protocol During Wound Care
Penalty
Summary
The facility failed to implement physician orders for pain management during wound care for a resident with second-degree burns, resulting in pain during wound care. The resident, who had severe cognitive impairment, suffered burns from a hot tea spill and required wound care twice daily. Despite physician orders to apply lidocaine ointment 10-15 minutes prior to wound care, staff did not adhere to this protocol, causing the resident significant pain during dressing changes. Observations revealed that nursing staff did not wait the required 10-15 minutes for the lidocaine to take effect before proceeding with wound care. During one instance, the staff waited only a few minutes before applying new dressings, and in another instance, they waited approximately one minute. The resident expressed pain during these procedures, indicating that the lidocaine was not given sufficient time to numb the area. Interviews with staff and family members confirmed that the resident experienced significant pain during wound care. The nurse practitioner and other staff members acknowledged the need to wait 10-15 minutes for the lidocaine to take effect, but this protocol was not consistently followed. The facility's pain management policy emphasized the importance of providing pain management consistent with professional standards and the resident's care plan, which was not adhered to in this case.
Latest citations in Michigan
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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