Hillsdale County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsdale, Michigan.
- Location
- 140 W Mechanic Street, Hillsdale, Michigan 49242
- CMS Provider Number
- 235197
- Inspections on file
- 20
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hillsdale County Medical Care Facility during CMS and state inspections, most recent first.
Multiple residents with severe cognitive impairment were subjected to physical and sexual abuse by other residents, including repeated aggressive behaviors and inappropriate sexual contact. Staff and management were aware of these incidents but failed to report them as abuse allegations to the state agency or conduct required investigations, instead treating them as personal issues between residents with dementia. Facility policy requiring immediate reporting and investigation of abuse was not followed, resulting in a lack of protection for vulnerable individuals.
A resident with multiple chronic conditions and new venous leg wounds did not receive wound care as ordered when an LPN placed black plastic trash bags over her lower legs for over two days to manage excessive drainage, without physician authorization. The bags were not removed or reported to the next shift, and the physician was not notified of the resident's change in condition. The resident's wounds deteriorated significantly, leading to cellulitis, sepsis, hospitalization, and eventual death. Documentation and interviews confirmed the resident did not refuse care, and there was incomplete documentation and lack of timely wound assessments.
Multiple incidents of physical and sexual abuse between residents with dementia were observed and reported by staff, but facility leadership failed to report these allegations to the state agency or conduct required investigations. Staff were discouraged from using accurate language in documentation, and abuse incidents were dismissed due to the cognitive status of those involved. This resulted in unaddressed and ongoing abuse, with no evidence of proper follow-up or protection for the affected residents.
The facility failed to report and investigate multiple allegations of abuse, including sexual and physical abuse, involving residents with severe cognitive impairment. Staff observed and documented incidents such as inappropriate sexual contact and physical aggression between residents, but these events were not reported to the state agency or thoroughly investigated as required by policy. The administrator and DON acknowledged that these incidents should have been reported, but they were not, resulting in a deficiency in abuse prevention and reporting.
A resident with severe cognitive impairment was observed being fondled by another resident with a history of inappropriate behavior. Multiple staff members witnessed or were informed of the incident, but no formal investigation or incident report was completed, and the event was not reported to the administrator as required by policy.
A resident with severe cognitive impairment and a history of dementia and anxiety was left unattended in a personal recliner chair with the footrest elevated, resulting in a fall and injury. The resident was unable to operate the chair's remote, and no safety or physician restraint audit had been conducted, leading to the use of the chair as a physical restraint without proper assessment.
A resident with cognitive impairment and mobility needs suffered a clavicle fracture after a CNA released the gait belt during a transfer, causing the resident to lose balance and fall. The care plan required one-person assist with a gait belt and walker, but the CNA let go of the belt to adjust a chair, leading to the incident. The DON confirmed staff are expected to maintain hold of the gait belt during transfers.
A resident in an LTC facility experienced multiple falls during staff-assisted transfers, resulting in severe injuries, including fractures. The facility failed to implement care-planned interventions, such as using a gait belt, contributing to the incidents. Observations showed the resident's call light was often out of reach, indicating inadequate supervision.
The facility failed to report allegations of abuse and inappropriate behavior involving four residents. A resident with moderate cognitive impairment alleged molestation, which was dismissed by the administrator without investigation. Another resident reported feeling intimidated by a male resident who entered her room uninvited, but the incident was not reported. Additionally, a resident with dementia made repeated allegations of staff misconduct, which were not reported to the state agency. The facility's failure to report these incidents highlights a deficiency in their reporting procedures.
The facility failed to investigate abuse allegations for four residents, including a cognitively impaired resident who claimed molestation, a resident who felt intimidated by another resident's behavior, and a resident with dementia who made accusations during care. The facility did not report these incidents to the state or conduct formal investigations, leading to a deficiency in handling potential abuse cases.
Two residents in an LTC facility were found with recliner controls intentionally kept out of reach, potentially constituting physical restraints. Despite staff's rationale for fall prevention, there were no documented assessments to evaluate the residents' ability to safely use the recliner controls or to determine if this practice was a restraint.
The facility failed to implement care planned interventions for a resident with a pressure ulcer due to a non-functioning air mattress. Another resident with dementia exhibited exit-seeking behavior for months before a care plan was developed. Staff interviews revealed a lack of responsibility and resources to address these issues.
A resident with benign prostatic hyperplasia and cognitive impairment experienced burning and purulent drainage at the catheter site, with no documented catheter care instructions in their care plan or medical record. The resident was sent to the emergency department for evaluation and treatment, where yeast and redness were found on the penis. Despite a urology consultation recommending twice-daily cleaning, there was no evidence of consistent catheter care being performed.
The facility failed to provide appropriate care and treatment for five residents with facility-acquired pressure ulcers. Inadequate documentation, lack of physician notification, and improper wound care led to the deterioration of wounds, severe infections, and eventual hospice care for some residents.
Failure to Protect Residents from Abuse and Inadequate Reporting of Resident-to-Resident Incidents
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse by other residents, as evidenced by multiple documented incidents involving residents with severe cognitive impairment. One male resident with dementia, anxiety, and depression repeatedly exhibited aggressive and violent behaviors toward a female resident with similar cognitive impairments. These behaviors included shoving, hitting, ramming a wheelchair into the female resident, and violently shaking her. Staff intervened to separate the residents during these incidents, but the events were not reported as abuse allegations to the state agency as required. Documentation and interviews revealed that staff and management were aware of the incidents, but the events were treated as personal issues between residents with dementia rather than as reportable abuse, contrary to facility policy and regulatory requirements. Further review of records and staff interviews indicated that the aggressive resident's behaviors were ongoing and escalating, with staff frequently attempting to redirect and separate the residents. Despite repeated reports from CNAs to supervisors and management, there were no changes in interventions beyond attempts at separation, and the incidents were not properly investigated or reported. The facility's abuse coordinator and DON acknowledged in interviews that the incidents should have been reported as abuse allegations but were not, and that this was a failure to follow required procedures. Additionally, documentation of the incidents was incomplete, and some staff were instructed not to use terms like "violent" in their reports. A separate incident involved a male resident with severe cognitive impairment who was observed fondling the breasts of a nonverbal female resident with dementia. Multiple staff members witnessed the event, separated the residents, and were instructed to keep them apart in the future. However, the incident was not reported to the abuse coordinator or state agency, and no investigation or incident report was completed. The facility's abuse policy defined such contact as sexual abuse and required immediate reporting and investigation, but this did not occur. The failure to report and investigate these incidents resulted in a lack of protection for vulnerable residents and a violation of their right to be free from abuse.
Failure to Follow Wound Care Orders and Improper Use of Plastic Bags Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary standards of care and services for wound and skin care management for a cognitively intact female resident with multiple comorbidities, including CHF, diabetes, hypertension, lymphedema, and cellulitis. The resident developed new venous wounds on her lower legs, which required daily dressing changes and specific wound care as ordered by the physician. Despite these orders, a nurse placed black plastic trash bags over the resident's lower legs for over two days to manage copious drainage, without physician authorization. The plastic bags were not removed or reported to the next shift, and the resident's condition was not communicated to the physician despite a significant change in wound drainage and frequency of dressing changes. When the wound nurse discovered the plastic bags, the resident's dressings were heavily saturated, and the wounds had significantly deteriorated, with the skin sliding off and increased pain reported. Documentation showed that the resident did not have a history of refusing care, and interviews with staff confirmed that the resident wanted to heal her wounds. There was also a lack of timely wound assessments and incomplete documentation regarding treatment refusals and physician notifications. The facility's wound nurse and DON confirmed that the use of plastic bags was not an acceptable practice and that physician orders were not followed. The resident subsequently developed cellulitis and sepsis, requiring hospitalization for septic shock and intravenous antibiotics. She was later discharged back to the facility on hospice care and died shortly thereafter. The investigation revealed that the nurse responsible for the improper treatment received only verbal education, and there was no evidence of a thorough incident or accident report being completed. The deficient practice directly contributed to the resident's rapid decline, hospitalization, and death.
Failure to Report and Investigate Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, and exploitation for multiple residents with severe cognitive impairment. Several incidents involving resident-to-resident physical and sexual abuse were observed, documented, and reported by staff to supervisors, but these incidents were not reported to the state agency as required by facility policy. Specifically, a male resident with dementia repeatedly exhibited aggressive and violent behaviors toward a female resident, including shoving, hitting, ramming with a wheelchair, and violently shaking her. Despite staff interventions and documentation of these events, the incidents were not reported to the Director of Nursing (DON) or Nursing Home Administrator (NHA) as abuse allegations, and no thorough investigations were conducted. Staff were instructed by leadership not to use terms like "violent" in documentation, and the rationale given for not reporting was that both residents had dementia. Additionally, another male resident with severe cognitive impairment was observed and reported by staff to have engaged in sexually inappropriate behavior toward a female resident, including fondling her breasts in a group setting. Multiple staff members witnessed the incident, separated the residents, and reported the event to nursing staff. However, there was no evidence of an incident report or investigation, and the NHA and DON were unaware of the event until questioned during the survey. The facility's abuse policy defined such actions as sexual abuse and required immediate reporting and investigation, which did not occur. Interviews with staff, including CNAs, nurses, and the social worker, revealed a pattern of underreporting and lack of follow-through on abuse allegations, particularly when incidents involved residents with dementia. Staff reported escalating behaviors, frequent altercations, and emotional distress experienced by the victims, but these were not addressed according to policy. The failure to report and investigate these incidents resulted in potential ongoing abuse and emotional harm to vulnerable residents.
Failure to Report and Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, and to report the results of investigations to the proper authorities as required by section 1150B of the Act. Multiple incidents involving residents with severe cognitive impairment, including dementia and Alzheimer's disease, were documented in which allegations of abuse, specifically sexual and physical abuse, were not reported to the state agency or thoroughly investigated. Staff observed and documented inappropriate and abusive behaviors, such as one resident fondling another's breasts and another resident physically assaulting a peer by shoving, hitting, and shaking, yet these incidents were not reported as required. Medical records and staff interviews revealed that residents involved were severely cognitively impaired and unable to protect themselves or communicate effectively. Staff, including CNAs and nurses, witnessed and intervened in abusive incidents, completed internal documentation, and reported events to supervisors. However, these reports did not result in formal investigations or notifications to the state agency. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this protocol was not followed. The administrator and DON acknowledged that these incidents should have been reported and investigated but were not, often due to the mistaken belief that resident-to-resident incidents involving dementia did not constitute reportable abuse. Further review of records and interviews indicated a pattern of escalating aggressive behaviors by certain residents, repeated staff interventions, and ongoing concerns expressed by staff to management. Despite multiple documented incidents and staff awareness, there was no evidence of completed incident reports, thorough investigations, or state notifications for the abuse allegations. The failure to report and investigate these incidents as required by federal and state regulations constituted a deficiency in the facility's abuse prevention and reporting practices.
Failure to Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment who was observed being fondled by another resident. Multiple staff members, including CNAs and an RN, witnessed or were informed of the incident in which one resident was seen grabbing another resident's breasts in the activity room. The incident was reported among staff, and measures were taken to separate the two residents during activities. However, there was no evidence that the incident was reported to the Nursing Home Administrator or that a formal investigation was initiated, as required by facility policy. The affected resident was nonverbal and used nonverbal cues to communicate, while the resident who committed the act had a history of inappropriate behavior and severe cognitive impairment. Despite staff awareness and documentation of the incident, the facility did not complete an incident report or conduct an investigation. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this process was not followed in this case.
Failure to Assess for Potential Physical Restraint in Cognitively Impaired Resident
Penalty
Summary
The facility failed to assess the potential for the use of a physical restraint for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia and anxiety and scored 4 out of 15 on the BIMS, was admitted with significant cognitive limitations. On one occasion, the resident was observed attempting to get out of a personal recliner chair with the footrest elevated, resulting in a fall and a hematoma to the forehead. The remote to control the footrest was out of reach, and staff confirmed that the resident did not have the cognitive ability to operate the remote independently. Despite facility policy requiring a safety audit of personal chairs for all residents, no such audit or physician restraint assessment had been completed for this resident's chair. The lack of assessment and oversight led to the resident being left unattended in a situation where the chair's configuration limited the resident's ability to rise independently, meeting the definition of a physical restraint as outlined in the State Operations Manual.
Failure to Maintain Supervision During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness and dementia, and a moderately impaired cognitive status, experienced a fall during ambulation that resulted in a right clavicle fracture. The resident required the assistance of one person for all transfers, with the use of a gait belt and a two-wheeled walker, as documented in the care plan. On the day of the incident, the resident was being assisted by a CNA while walking from the bathroom to her personal recliner. During the transfer, the CNA let go of the resident's gait belt to pull the resident's chair closer, at which point the resident lost her balance and fell in the bathroom doorway, landing on her right side and hitting her head on the bathroom door. The CNA acknowledged in an interview that she had a lapse in judgment by removing her hand from the gait belt during the transfer, which directly led to the resident's fall and subsequent injury. The Director of Nursing confirmed that the facility's expectation is for staff to maintain their hold on the gait belt while transferring residents. The incident was corroborated by the resident's account, medical record review, and staff interviews.
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident during staff-assisted transfers, leading to multiple falls and injuries. The resident, a cognitively intact elderly female with a history of left hip replacement, heart failure, and other medical conditions, experienced falls on two separate occasions during staff-assisted transfers. These incidents resulted in significant injuries, including bilateral pelvic fractures, a fractured left elbow, and a non-displaced fracture near her left total hip site. The resident was dependent on staff for all activities of daily living and was at high risk for falls, as indicated by her care plan and fall assessments. On March 10, 2024, the resident fell during a transfer outside the bathroom door, resulting in severe injuries. The CNA assisting the resident at the time did not use a gait belt, as the resident reportedly did not like it. This lack of adherence to the care-planned intervention contributed to the fall and subsequent injuries. The CNA later received education on the importance of using a gait belt during transfers and notifying a nurse if a resident refuses it. Despite this, the resident experienced another fall on October 21, 2024, during a transfer from a motor-chair to a personal chair. The LPN assisting the resident was unsure if she was holding the gait belt correctly, leading to the resident losing balance and falling backward. The facility's failure to implement care-planned interventions, such as ensuring the use of a gait belt during transfers, directly contributed to the resident's falls and injuries. Observations revealed that the resident's call light was often out of reach, and there were instances of inadequate supervision. The facility's policy on transfers with a gait belt was not consistently followed, and the lack of complete investigations and witness statements further highlighted deficiencies in the facility's safety protocols.
Failure to Report Allegations of Abuse and Inappropriate Behavior
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act for four residents. Resident #31, who had moderate cognitive impairment, made a statement alleging molestation, which was not reported by the administrator. The administrator did not report the allegation because the resident's son, who was on the phone during the statement, dismissed it as untrue. However, there was no documentation of the date and time of the alleged incident, and the administrator relied solely on the son's dismissal without further investigation. Resident #55, who was cognitively intact, reported an incident where a male resident entered her room uninvited, causing her to feel intimidated and uncomfortable. The male resident, who had severe cognitive impairment and a history of wandering, was known to enter other residents' rooms and expose himself. Despite these behaviors, no facility-reported incidents were documented, and the nursing home administrator did not report the incident to the state. Staff interviews revealed that the male resident's actions caused anxiety among female residents, but the facility failed to report these incidents as allegations of abuse. Resident #478, who had dementia and Alzheimer's disease, made repeated allegations of staff being mean or performing care in a sexual manner. These allegations were not reported to the state agency, and no facility-reported incidents were documented. Staff interviews indicated that the resident frequently displayed paranoia and made accusations, but the nursing home administrator was unaware of these allegations. The facility's failure to report these allegations and conduct investigations highlights a deficiency in their reporting procedures.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse for four residents, leading to a deficiency in handling potential abuse cases. Resident #31, who had moderate cognitive impairment, made a statement about being molested, which was not investigated by the administrator. The administrator relied on the resident's son's dismissal of the claim without conducting a formal investigation, despite the lack of a specific date and time for the alleged incident in the progress notes. Resident #55, who was cognitively intact, reported feeling intimidated and uncomfortable when a male resident entered her room uninvited. The male resident, who had severe cognitive impairment and a history of wandering, was known to have entered other residents' rooms and exposed himself. Despite these incidents, no formal investigation was conducted, and the facility did not report the incidents to the state. The social worker acknowledged the impact of the male resident's behavior on female residents but did not document follow-up actions. Resident #478, who had dementia and Alzheimer's disease, made allegations of being molested during care, which were not investigated. The resident frequently displayed paranoia and made accusations against staff, but these were not reported or investigated as potential abuse. The nursing home administrator was unaware of these allegations and stated that they should have been reported and investigated. No facility-reported incidents related to these allegations were found in the reporting system.
Failure to Assess Use of Recliner Controls as Potential Restraints
Penalty
Summary
The facility failed to assess the use of possible physical restraints for two residents, leading to a deficiency in ensuring residents are free from restraints unless medically necessary. Resident #96, who has Parkinson's disease and moderate cognitive impairment, was observed multiple times seated in a recliner with the leg rest elevated and the remote control out of reach. Staff reported that the remote was intentionally kept out of reach to prevent the resident from standing and potentially falling. Despite a physician's order to keep the controls out of reach for safety, there was no documented assessment to determine if this constituted a restraint. Similarly, Resident #118, with a history of falls and severe cognitive impairment, was also observed in a recliner with the controls out of reach. After a fall incident where the resident attempted to climb out of a manual recliner, the facility replaced it with an electric recliner and kept the remote control hidden. Staff confirmed that this was a common practice to prevent residents from self-transferring and falling. However, there was no documented assessment to evaluate the resident's ability to safely use the recliner controls or to determine if keeping the controls out of reach was a restraint. Interviews with staff, including CNAs, RNs, and LPNs, revealed a consistent practice of keeping recliner controls out of reach for safety reasons, but without proper assessments to justify this as a non-restraint measure. The facility's Director of Nursing and Risk Manager acknowledged the practice but failed to provide documentation of any assessments conducted to evaluate the necessity and safety of this approach. The lack of assessments and documentation led to the deficiency finding by the surveyors.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to implement care planned interventions for a resident with a stage two pressure ulcer. The resident was observed on multiple occasions with an air mattress that was not functioning due to the pump being unplugged or turned off. Despite the care plan indicating the use of an air mattress to assist with pressure reduction, staff interviews revealed uncertainty about who was responsible for ensuring the mattress was functioning. The resident, who had moderate cognitive impairment, reported having a wound on their buttocks that was being treated. Another resident, who was cognitively impaired and diagnosed with dementia and Alzheimer's disease, exhibited exit-seeking behavior over several months. Despite this behavior being documented in various notes, a care plan addressing the exit-seeking was only developed months later. Staff interviews indicated that the facility lacked a wanderguard alarm system, and staff attempted to manage the behavior by locking the front doors. The social worker only recently added the exit-seeking behavior to the care plan. The Director of Nursing stated that she would expect a care plan to be in place for residents displaying exit-seeking behavior. The delay in developing a comprehensive care plan for the resident with exit-seeking behavior and the failure to ensure the air mattress was functioning for the resident with a pressure ulcer highlight deficiencies in the facility's care planning and implementation processes.
Failure to Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care and perineal care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with benign prostatic hyperplasia and had a cognitive impairment, experienced burning in the perineal area and penis, with purulent drainage and redness observed at the catheter insertion site. Despite these symptoms, there were no documented instructions or orders for catheter care in the resident's care plan, physician orders, Kardex, or electronic medical record. The lack of documented catheter care led to the resident being sent to the emergency department for evaluation and treatment of uncontrolled pain and penile discharge. Hospital staff discovered yeast and redness on the resident's penis, and the resident was discharged with an antifungal cream. A subsequent urology consultation recommended twice-daily cleaning of the penis, but there was no evidence that catheter care was consistently performed. A registered nurse confirmed the absence of catheter care orders and documentation of care being performed.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that five out of seven residents received appropriate care and treatment for facility-acquired pressure ulcers. Resident #1 had a stage 4 pressure ulcer that developed at the facility, with multiple instances of inadequate documentation, lack of physician notification, and improper wound care. The wound deteriorated over time, with no consistent treatment plan or proper wound measurements documented. The resident's condition worsened, leading to hospitalization and eventual hospice care due to severe infection and osteomyelitis. The care plan for Resident #1 was not updated appropriately to reflect the changes in the wound condition. Resident #5 developed a deep tissue injury (DTI) pressure ulcer on the right heel, which was not properly documented or treated. The wound deteriorated into a necrotic gangrenous ulcer with MRSA infection. The wound care nurse failed to notify the physician of the wound's condition and did not follow the wound clinic's treatment orders. The resident experienced significant pain and was eventually placed on hospice care. The wound care nurse admitted to changing treatment orders without proper oversight and lacked adequate wound care education. Resident #3 had multiple pressure ulcers, including a stage 2 coccyx ulcer and a suspected DTI on the right heel. The facility failed to complete weekly skin/wound assessments and did not provide proper documentation or treatment for the wounds. The resident's condition was not adequately monitored, and there was no evidence of provider oversight for the wound care program. The lack of proper wound care and documentation led to the deterioration of the resident's wounds, with no timely intervention or appropriate treatment provided.
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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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