Helen Newberry Joy Hltcu Golden Leaves Living Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Newberry, Michigan.
- Location
- 502 West Harrie Street, Newberry, Michigan 49868
- CMS Provider Number
- 235705
- Inspections on file
- 25
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Helen Newberry Joy Hltcu Golden Leaves Living Cent during CMS and state inspections, most recent first.
A resident with multiple sclerosis and limited mobility developed a worsening stage 3 pressure injury on the right heel due to staff failing to implement physician-ordered and care plan interventions, such as heel offloading and use of pressure-reducing devices. Despite clear orders and recommendations, the resident was observed without appropriate support surfaces or devices, and documentation showed the wound increased in size. The care plan and Kardex lacked necessary interventions, and a pressure-eliminating boot ordered by a consultant was not provided to the resident.
A resident with severe cognitive impairment and wandering behaviors repeatedly entered the rooms of other residents, taking or damaging their personal belongings and, at times, becoming physically aggressive. Despite the use of mesh barriers and staff attempts to monitor the situation, multiple residents experienced fear, frustration, and emotional distress due to the ongoing intrusions and loss of property. Staff acknowledged the difficulty in preventing these incidents, and documentation showed a persistent pattern of such behaviors over several months.
Multiple residents experienced physical abuse, fear, and emotional distress due to repeated assaults by a resident with severe dementia and a history of aggression. Staff did not consistently implement or document effective interventions, and education on managing aggressive behaviors was incomplete, leaving residents at ongoing risk of harm.
The facility did not provide written notification of the bed hold policy to residents or their representatives during transfers to hospitals. Staff interviews revealed a lack of awareness and implementation of the policy, with no notifications completed or forms available. The facility's policy required notification by the LPN or social work designee, but this was not followed.
A resident with intact cognition and low elopement risk was improperly restrained with a wander guard, causing discomfort and distress. The facility lacked a policy on the use of such devices, leading to the inappropriate restriction of the resident's freedom of movement.
The facility failed to prevent elopement for two residents, one with intact cognition and another with severe cognitive impairment. The first resident disabled her alarm and exited to the parking lot, while the second resident, despite an active alarm, was found near a hospital after passing multiple exits. Staff were unaware of the alarms due to system limitations and lack of supervision.
A resident with dementia, anxiety, and depression exhibited significant behavioral changes, including expressions of guilt and distress. Despite these changes, the LTC facility failed to reassess the resident's condition, update the care plan, or make referrals to behavioral health services. Interviews revealed a lack of resources and actions to address the resident's needs.
The facility failed to provide necessary social services to two residents, leading to potential psychosocial decline. One resident, with depression and anxiety, had no social service assessments or discharge plans, while another resident with dementia exhibited distressing behaviors without intervention. The facility lacked a social worker, contrary to its policy.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident with severe cognitive impairment was given Risperidone without family consent, despite having a DPOA. Another resident with intact cognition received haloperidol and lorazepam without consent. The ADON was unaware of the requirement for signed consent, and the facility lacked an acting Social Services Director.
A resident experienced a delay in receiving necessary PT/OT services, leading to a decline in physical mobility. Despite being admitted with conditions requiring therapy, the facility failed to provide these services due to missing paperwork and lack of coordination among staff. Interviews revealed that PT/OT were not included in standing orders, and the resident expressed concerns about worsening weakness and balance issues.
A resident's pressure injuries worsened to stage 3 due to the facility's failure to assess, monitor, and manage the wounds properly. The DON initially misclassified the injuries, and the care plan lacked necessary interventions. Infection control practices were not followed during wound care, and the wound consultant was unavailable, leaving nursing staff without formal guidance.
A resident with severe dementia and a history of falls experienced multiple falls and injuries due to the facility's failure to assess, develop, and revise care plan interventions, provide adequate supervision, and investigate falls for root cause. Despite the resident's high fall risk, the care plan was not updated, and incident reports and nursing assessments were incomplete or missing. The facility did not follow its policy on falls, leading to ongoing fall risks.
The facility failed to implement proper infection control practices during medication administration, including inadequate disinfection of equipment and poor hand hygiene by an LPN. Personal items were improperly stored with resident medications, increasing cross-contamination risk. Additionally, the facility did not adhere to its water management plan for Legionella control, lacking documentation of required measures and corrective actions for a positive bacterial test.
The facility failed to report accurate PBJ information to CMS, leading to a deficiency in staffing levels. During a COVID-19 outbreak, the DON and ADON covered shifts but their hours were not included in the report due to an oversight by the administrative assistant responsible for submissions.
The facility failed to ensure personal privacy during medication administration for six residents, as medications were administered in the dining room in the presence of other diners. Observations included insulin injections and oral medications being given without privacy, contrary to the facility's policy. The DON acknowledged the lack of privacy during these medication passes.
A long-term care facility experienced a 32% medication error rate due to improper insulin pen preparation and administration, and incorrect documentation of medication administration. Errors included not cleansing insulin pen hubs, incorrect priming, and failure to administer a prescribed medication. The Director of Nursing confirmed the improper procedures.
A resident was discharged to an assisted living facility without a completed discharge summary, including a physician order, recapitulation of stay, and medication reconciliation. Interviews with the DON and ADON revealed a lack of awareness of discharge documentation requirements, despite the facility's policy outlining necessary steps.
A facility failed to follow ADL care plans and policies for two residents, leading to injuries and unmet care needs. One resident, with a history of cerebrovascular accident and fragile skin, sustained bruising and skin tears due to improper handling by a CNA who did not follow the care plan requiring two staff members and a draw sheet for repositioning. Another resident reported feeling unsafe and rushed during care, as the CNA was described as rough and aggressive. The facility's Standards of Care policy, which emphasizes focusing on the resident and preventing shear injuries, was not adhered to.
A facility failed to assess and document the need for bed rails for a resident with dementia and hemiplegia. Despite the care plan indicating no bed rail use, observations showed bilateral side rails in use without a physician order or consent. The facility's guidelines require an interdisciplinary team recommendation, a physician order, and resident consent for bed rail implementation.
A facility failed to prevent a resident from eloping twice due to malfunctioning doors and inadequate supervision. The resident, identified as a high elopement risk, left through doors with disabled alarms. Additionally, the facility did not maintain properly functioning fire safety doors, contributing to the incidents. The environment was unsafe, with fall hazards like misplaced mats and unreachable call lights, and a resident sustained a burn due to improper bed placement. Damaged entrance steps further compromised safety.
Failure to Implement Pressure Injury Interventions Resulting in Worsening Wound
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, who was non-ambulatory and at risk for pressure injuries, developed a stage 3 pressure injury on the right heel while residing in the facility. Despite physician orders and care plan interventions to float the resident's heels while in bed and to offload pressure while in a wheelchair, staff failed to implement these interventions. Observations revealed the resident was repeatedly found with both feet placed directly on the floor without any pressure-reducing device while in a wheelchair, and with heels resting directly on the mattress while in bed. The resident confirmed that staff had not provided pressure-reducing boots or elevated her heels as required. Review of the medical record showed that the pressure injury was first identified as stage 3 and subsequently worsened in size over time. Documentation indicated that the wound was not healing, with saturated dressings, increased wound size, and the presence of slough and odor. The care plan and Kardex did not include specific interventions to reduce pressure on the heel while the resident was in the wheelchair, and staff were not directed to implement pressure-relieving measures. A consultant physician had recommended and ordered a pressure-eliminating boot, but this order was not implemented, and the boot remained unused in the DON's office. Interviews with the DON and staff confirmed a lack of awareness and implementation of the required interventions. The DON admitted that the resident should have had pressure-reducing boots or similar devices and acknowledged that the care plan and Kardex were incomplete regarding pressure injury interventions. Facility policies and national guidelines require elevation of heels and use of appropriate devices to prevent and treat pressure injuries, but these standards were not followed, resulting in the worsening of the resident's pressure injury.
Failure to Prevent Resident-to-Resident Intrusions and Property Loss
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment and wandering behaviors from repeatedly entering the rooms of other residents and taking or destroying their personal belongings. Multiple residents reported that this individual entered their rooms, removed or damaged their possessions, and in some cases, became physically aggressive when confronted. The affected residents expressed fear, frustration, and emotional distress as a result of these incidents, with some reporting physical altercations, including being struck or choked by the resident in question. Observations revealed that the facility attempted to use mesh-type barriers with stop sign notifications across doorways to prevent the resident from entering other rooms. Despite these measures, staff interviews indicated that it was nearly impossible to keep the resident from wandering into other rooms and taking items, as the resident was frequently in the hallways and staff could not consistently monitor or redirect her. Documentation in the electronic medical records showed numerous progress notes over several months detailing the resident's ongoing behaviors, including wandering, entering other residents' rooms, and taking or disturbing their belongings, often resulting in distress among other residents. The residents affected by these incidents were generally cognitively intact and valued the importance of maintaining their personal belongings, as documented in their Minimum Data Set (MDS) assessments. Staff, including CNAs and LPNs, acknowledged the ongoing issue and the negative impact on the residents' sense of safety and well-being. The Assistant Director of Nursing was unable to provide a clear answer regarding effective interventions to prevent these incidents, and the facility's actions were limited to placing barriers and attempting to monitor the resident, which proved insufficient.
Failure to Protect Residents from Physical Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident with a documented history of aggressive behaviors. Several incidents occurred in which a resident with severe vascular dementia and significant cognitive impairment physically assaulted other residents, including hitting, choking, and entering their rooms to take personal belongings. These altercations resulted in emotional distress, fear, and physical harm, such as pain and reddened marks on the necks of the affected residents. Staff interviews and medical records confirmed that the aggressive resident had a pattern of physical and verbal aggression toward others, and that other residents were fearful of further harm. Despite repeated incidents, staff did not consistently implement or document effective interventions to prevent further abuse. Care plans for the aggressive resident were updated reactively after each event, but interventions such as 1:1 supervision were not maintained continuously, and staff reported that redirection was not always successful. There was a lack of clear, resident-centered guidelines for managing the resident's behaviors, and staff did not receive comprehensive or consistent education on how to address these situations. Documentation of staff education was incomplete, with attendance records showing that only a fraction of the required staff participated. The facility's own policy required proactive identification, correction, and intervention in situations likely to lead to abuse, including the assessment and care planning for residents with aggressive behaviors. However, the facility did not ensure that all staff were trained or that interventions were consistently implemented and evaluated. As a result, residents continued to be exposed to the risk of physical abuse, and some experienced repeated incidents of harm and emotional distress.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives in cases of transfer to a hospital or therapeutic leave. This deficiency was identified for four residents who were reviewed for notice of the bed hold policy. The facility's Electronic Medical Record (EMR) confirmed that these residents were discharged to acute care facilities on specific dates, yet there was no evidence of written notification regarding the bed hold policy being provided to them or their representatives. Interviews with facility staff revealed a lack of awareness and implementation of the bed hold policy. The Chief Nursing Officer and the Assistant Director of Nursing admitted that notifications of the bed hold policy had not been completed for some time, and there were no forms or procedures in place for such notifications. Additionally, the Administrative Assistant stated that no bed hold policy letters had been sent to residents or families since July 2022. The facility's policy on discharge and transfer, which was last revised in July 2024, indicated that the LPN or social work designee should notify families of the bed hold policy, but this was not being followed. The facility was unable to provide a bed hold policy to the surveyor before the exit.
Failure to Ensure Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure freedom from physical restraints for a resident, identified as Resident #10 (R10), who was reviewed for restraints. R10, who has diagnoses including Parkinson's disease, hypertension, dementia, and hyperlipidemia, was admitted to the facility with intact cognition as indicated by a perfect score on the Brief Interview of Mental Status (BIMS). Despite being assessed as a low risk for elopement, with a score of 1 out of 11 on the Elopement Risk Evaluation, R10 was equipped with a wander guard on the left ankle. During an interview, R10 expressed discomfort and confusion about the presence of the device, stating it was tight and uncomfortable. The Assistant Director of Nursing (ADON) confirmed the use of the wander guard to prevent R10 from approaching exit doors, despite R10 never having attempted to leave. The facility lacked a policy on the use of wander guards or restraints, which contributed to the deficient practice of restraining R10 without medical necessity, resulting in physical discomfort and psychosocial distress.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement appropriate interventions to prevent unsafe wandering and elopement for two residents, resulting in two elopements. Resident #9, who had intact cognition, was able to exit the facility by removing her tether and disabling the alarm on her door. She was found in the parking lot after being outside for a few minutes. The door alert system did not alarm due to the resident's actions, and there were no staff present to prevent her exit. The Chief Nursing Officer was unaware of why the exit doors did not alarm, and the resident confirmed she could disable the alarm and had previously removed her bracelet. Resident #7, who had severe cognitive impairment, was found near the emergency room doors of an adjacent hospital after eloping from the facility. The resident exited through the same doors as Resident #9 during mealtime when staff were occupied elsewhere. Although the resident's tether alarm was activated, the CNA did not hear it due to the pager being left in the office, as it did not work in the hallway. The resident passed multiple exits before being noticed by hospital staff, indicating a lack of effective supervision and response to the alarm system.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with active diagnoses of dementia, anxiety, depression, and hypertension. The resident, who had intact cognition as indicated by a BIMS score of 14 out of 15, exhibited significant behavioral changes over a period of time. These behaviors included expressions of extreme guilt, self-punishment, agitation, and anxiety, as well as making alarming statements about death and distress. Despite these changes, the facility did not reassess the resident's condition, update the care plan with new interventions, or make referrals to behavioral health services. Interviews with facility staff revealed a lack of resources and actions taken to address the resident's behavioral health needs. The Chief Nursing Officer admitted that the facility did not have a social worker or a contract with a behavioral support agency. The Assistant Director of Nursing acknowledged that no reassessment or referrals were made despite the resident's changing moods and behaviors. The facility's assessment and policy indicated the need for behavioral and mental health providers, yet these were not utilized, leading to the deficiency in care for the resident.
Failure to Provide Social Services
Penalty
Summary
The facility failed to provide necessary social services to two residents, resulting in a potential for psychosocial decline. Resident #3 was admitted with diagnoses including depression and anxiety disorder. Despite expressing feelings of depression and hopelessness, and a desire to discuss living arrangements near a family member, there were no social service assessments, notes, or discharge plans documented for this resident. This lack of social service intervention left the resident's psychosocial needs unaddressed. Resident #9, who was admitted with dementia and anxiety, exhibited behaviors indicating significant distress, such as expressing extreme guilt, self-punishment, and agitation. The resident's behavior included staying isolated in their room, making statements about self-worth, and causing disturbances in the facility. Despite these clear signs of distress, the facility did not have a social worker or designee to address these issues, as confirmed by the Chief Nursing Officer. The facility's policy required social service assessments and ongoing interventions, which were not provided, contributing to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for two residents, leading to a deficiency in the administration of these medications. Resident #7, who was admitted with diagnoses including diabetes mellitus, dementia, and insomnia, had severe cognitive impairment as indicated by a BIMS score of 00. Despite having a Durable Power of Attorney (DPOA) activated, the facility did not obtain informed consent from the family for the administration and increase of Risperidone, a psychotropic medication, which was started and increased over several months. The Assistant Director of Nursing (ADON) confirmed the absence of a signed consent and was unaware of the requirement to obtain one. Similarly, Resident #9, who was admitted with diagnoses including hypertension, dementia, and depression, had intact cognition with a BIMS score of 14. The resident was administered haloperidol and lorazepam without obtaining informed consent. The ADON also confirmed the lack of a signed consent for this resident and was unaware of the necessity to obtain it. The facility's policy on psychotropic medication use, which requires notifying the family or responsible party of any medication changes, was not adhered to. The absence of an acting Social Services Director at the time of the survey was noted by the ADON.
Failure to Implement Rehabilitative Services
Penalty
Summary
The facility failed to implement necessary rehabilitative services for a resident, resulting in a delay in assessment and treatment, and a decline in the resident's physical mobility. The resident was admitted with active diagnoses including depression, anxiety disorder, malnutrition, and hypertension, and was noted to require physical and occupational therapy (PT/OT) due to physical deconditioning. However, the Minimum Data Set (MDS) assessment showed zero minutes of PT and OT, and the resident expressed concerns about worsening weakness and balance issues, fearing further decline. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's therapy needs. The Assistant Director of Nursing and Administrative Assistant were unable to locate therapy notes or admission paperwork for the resident. The Chief Nursing Officer acknowledged a delay in therapy services, and the Director of Nursing could not recall reviewing the resident's admission paperwork. The admitting nurse did not request PT/OT orders, and it was noted that PT and OT were not included in the standing orders for new admissions, despite facility policies indicating that residents should receive a functional assessment on admission to determine therapy needs.
Failure to Manage and Document Pressure Injuries
Penalty
Summary
The facility failed to properly assess, monitor, and manage pressure injuries for a resident, leading to the worsening of existing wounds and the development of new stage 3 pressure injuries. Initially, the Director of Nursing (DON) claimed there were no pressure injuries in the facility, misclassifying the resident's wounds as shearing injuries. The resident, who was readmitted after hospitalization for sepsis, had documented pressure injuries upon return, but the facility did not maintain consistent wound assessments or updates in the medical record for June 2024. During a wound care observation, a nurse failed to follow proper infection control practices, such as changing gloves and washing hands between tasks. The nurse also did not measure the wounds, stating that only the wound consultant performed measurements. The DON later acknowledged the wounds had advanced to stage 3 pressure injuries but was unaware of when they were initially identified. The facility's care plan did not reflect the resident's actual skin breakdown or include necessary interventions like a low air loss mattress, which was only provided after the wounds worsened. The facility's wound consultant was unavailable due to injury, leaving the nursing staff to manage the resident's wound care without formal guidance. The facility's policy required weekly wound measurements and assessments, which were not consistently documented. The lack of timely intervention and proper documentation contributed to the resident's deteriorating condition, highlighting significant lapses in wound care management and infection control practices.
Failure to Address Fall Risks and Update Care Plans
Penalty
Summary
The facility failed to accurately assess, develop, and revise care plan interventions, provide adequate supervision, and investigate falls for root cause, which led to multiple falls and injuries for a resident with severe dementia and a history of falls. The resident was admitted with a known fall risk, yet the care plan was not updated to reflect this risk, and interventions were not adequately documented or implemented. Despite experiencing several falls, including one that required emergency department transfer for facial suturing, the facility did not conduct thorough investigations or update the care plan to prevent recurrence. The resident experienced multiple falls within a short period, with injuries ranging from lacerations and skin tears to bruising and abrasions. Incident reports and nursing assessments were either incomplete or missing, and the care plan was not updated to reflect the resident's high fall risk. The facility's Director of Nursing admitted that investigations had not been completed for the falls, and the care plan was not updated after each fall occurrence. The resident's care plan inaccurately documented a low fall risk despite evidence to the contrary. The facility's policy on falls and suspected falls was not followed, as care plans were not developed or revised with appropriate goals and interventions to decrease fall risk. The Fall Team Committee did not review falls as required, and necessary interventions were not implemented. The lack of documentation and investigation into the causal factors of the falls contributed to the ongoing risk and recurrence of falls for the resident.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration for several residents. Observations revealed that an LPN used continuous blood glucose monitors in contact with residents' clothing and placed them on the medication cart without barriers or disinfection. Additionally, the LPN did not cleanse insulin pen hubs with alcohol before attaching needles and failed to perform hand hygiene at critical points, such as before donning gloves or after removing them. The LPN also placed personal items, like a scrub jacket and a phone, in the medication cart with resident medications, further risking cross-contamination. The Director of Nursing (DON) acknowledged these infection control concerns, confirming that placing used clothing in the medication cart and failing to disinfect equipment or perform hand hygiene were unacceptable practices. The DON also confirmed that personal phones should not be stored in the medication cart and that insulin pen hubs should be cleaned with alcohol before use. These lapses in infection control practices posed a risk of cross-contamination and the spread of infectious diseases among the facility's residents. In addition to the infection control issues, the facility failed to implement its water management plan for controlling Legionella bacteria. The plan required specific control measures, such as confirming source water safety and quality, maintaining water heater temperatures, and performing regular flushing and disinfectant checks. However, the facility did not provide documentation of these measures or corrective actions for a positive bacterial test result, indicating a lack of adherence to the water management plan and potential risk of Legionella spread.
Inaccurate PBJ Reporting Due to Staffing Oversight
Penalty
Summary
The facility failed to report accurate Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in a deficiency related to staffing levels. During the fiscal year Quarter 2 of 2024, the facility was found to have triggered a metric for failing to maintain licensed nursing coverage 24 hours a day on several specific dates. An interview with the Long Term Care Administrative Assistant, identified as Staff H, revealed that the deficiency occurred due to an oversight during a COVID-19 outbreak when multiple staff members called off sick. The Director of Nursing (DON) and Assistant Director of Nursing (ADON), who are salaried and do not clock in, covered the shifts, but their hours were not included in the PBJ report. Staff H admitted to forgetting to account for their hours, and no further documentation was provided to prove coverage on the affected days.
Lack of Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure personal privacy during medication administration for six residents during a medication pass in the dining room. Observations revealed that medications, including insulin injections and oral medications, were administered in the presence of other diners, compromising the residents' privacy. For instance, a resident received a quick-acting insulin injection in her upper left arm while seated at a dining room table with other residents nearby. Another resident had her blood glucose level checked using a continuous glucose monitor while seated with another resident. Additionally, a resident was administered long-acting insulin in full view and hearing distance of other diners, with the nurse lifting the resident's blouse and pulling down her pants to expose her lower abdomen for the injection. The facility's Pharmacy - Medication Administration policy, reviewed in October 2020, requires that procedures be explained to residents and appropriate privacy be provided during medication administration. However, the Director of Nursing acknowledged that medications were routinely passed in the dining room, and agreed that there was a lack of privacy during these medication passes. This practice resulted in the explanation and administration of medications within visual and auditory view of fellow diners, violating the residents' right to personal privacy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 32 percent error rate during the observed medication administration. Eight errors were identified out of 25 opportunities. The errors involved improper preparation and administration of insulin pens and a powdered laxative. Specifically, insulin pen needles were placed on the pen hub without cleansing with alcohol, and the pens were not primed correctly. Additionally, a prescribed medication, Januvia, was not administered to a resident, yet it was incorrectly documented as given. The errors affected multiple residents, including one with Type 2 Diabetes Mellitus. The facility's medication administration policy, which requires documentation of all medications administered and any withheld or omitted, was not followed. The Director of Nursing confirmed the improper procedures and acknowledged the need for larger cups for proper laxative preparation. The facility's failure to adhere to proper medication administration protocols led to these deficiencies.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to an assisted living facility. The resident, who had diagnoses including arthritis, malnutrition, anxiety disorder, COPD, and adult failure to thrive, was discharged without the necessary documentation. The resident's progress notes indicated that medications and a medication list were provided at discharge, but there was no documentation of a physician order for discharge, recapitulation of stay, or medication reconciliation. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that they were unaware of the discharge documentation requirements. The ADON confirmed that she performed the discharge but did not complete or retain any documentation. The facility's policy outlined specific steps for discharge, including physician orders, recapitulation of stay, and documentation, none of which were followed in this case.
Failure to Follow ADL Care Plans Results in Resident Injuries
Penalty
Summary
The facility failed to adhere to resident person-centered care plans and ADL policy for two residents, resulting in injuries and unmet care needs. Resident R3, who has a history of cerebrovascular accident with left-sided weakness and fragile skin, was mistreated by a CNA. The CNA did not follow R3's care plan, which required assistance from two staff members and the use of a draw sheet for turning and repositioning. Instead, the CNA attempted to assist R3 alone, leading to bruising and skin tears on R3's right arm, which is his functional arm. The CNA admitted to grabbing R3's arm and hand during the transfer, causing the injuries, and did not notice the skin tears until after care was provided. Resident R12 also reported feeling unsafe and rushed during ADL care by the same CNA, who was described as too rough and aggressive. The facility's Standards of Care policy emphasizes focusing on the resident rather than the task, not rushing, and using a draw sheet to prevent shear injuries. However, these standards were not followed, leading to R12 feeling rushed and having unmet care needs. The report highlights the facility's failure to provide adequate care and assistance for residents unable to perform ADLs independently.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments to determine the need for bed rails for a resident diagnosed with dementia and hemiplegia affecting the left nondominant side. The resident's Minimum Data Set (MDS) assessment did not indicate the use of bed rails, yet observations on multiple occasions revealed that the resident's bed had bilateral side rails attached and in the upright position. The Director of Nursing (DON) confirmed the presence of the bed rails, which were supposed to be zip-tied and not in use according to the resident's care plan. Further review of the resident's records showed no physician order or consent for the use of bed rails, contradicting the facility's Bed Rail Guidelines and Assessments. These guidelines require an interdisciplinary team recommendation, a physician order, and a resident consent form for bed rail implementation. The resident's care plan also indicated a high risk for falls and explicitly stated that bed rails were not to be used, highlighting a significant oversight in adhering to established protocols.
Facility Fails to Prevent Resident Elopement and Maintain Safety Standards
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from eloping twice within a week. The resident, who had a history of elopement and was identified as a high elopement risk, managed to leave the facility through malfunctioning doors. The first incident occurred when the resident exited through a dining room door that was not properly alarming due to a disabled alarm system. The second elopement happened when the resident pushed open the main entrance door, which was not re-engaged as it should have been, allowing the resident to leave the premises without staff noticing immediately. Additionally, the facility did not maintain properly functioning fire safety doors, which contributed to the elopement incidents. Observations revealed that several doors, including doors #4, #5, and #11, were not functioning correctly, with issues such as alarms not engaging and magnets not releasing properly. Despite daily checks being documented, these malfunctions were not addressed in a timely manner, leading to the resident's ability to elope. The facility's maintenance and communication processes were inadequate, as evidenced by the lack of a policy for timely completion of work orders and the absence of an elopement book for staff reference. The facility also failed to ensure a safe environment to reduce fall risks for residents. Observations showed that fall mats were left on the floor when not in use, creating trip hazards, and call lights were out of reach for residents, increasing the risk of falls. Furthermore, a resident sustained a burn injury due to improper bed placement near a radiator, highlighting the lack of a policy for safe bed positioning. The facility's environment was further compromised by damaged concrete entrance steps, posing potential injury risks to visitors, staff, and residents.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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