Lake Woods Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskegon, Michigan.
- Location
- 1684 Vulcan Street, Muskegon, Michigan 49442
- CMS Provider Number
- 235116
- Inspections on file
- 25
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lake Woods Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted for orthopedic aftercare and dementia had a hospital After Visit Summary specifying a scheduled post-op orthopedic follow-up, but facility staff did not review and act on this information at admission. The resident’s significant other later reported that the appointment had been missed, and documentation showed the follow-up did not occur until a later date. The MRM, who had been on leave, found no record that the appointment was noted or scheduled by covering staff, and the DON could not determine or document why the original post-op visit was missed.
A resident with significant immobility and multiple risk factors developed a stage 3 pressure ulcer after staff failed to consistently use pressure-relieving devices, did not know the correct settings for a specialty air mattress, and lacked documentation and communication regarding care refusals. The care plan interventions were not reliably implemented, and there was no process to determine the cause of the ulcer or to involve family in managing refusals.
Surveyors found that the facility did not have an active plan to reduce Legionella and other waterborne pathogens, as evidenced by discolored water, lack of regular flushing in soiled utility rooms, spa rooms, janitor sinks, and the laundry room, and incomplete water testing practices. Maintenance staff confirmed that flushing was not routinely performed in these areas, and annual water testing was limited to cold water samples.
Two severely cognitively impaired residents were involved in a physical abuse incident when one resident with a history of wandering entered another's room and was physically assaulted. Despite prior interventions for wandering and confusion, the resident was able to access another room unsupervised, leading to the incident. Staff and witness statements confirmed the abuse occurred before staff intervened.
A resident with congestive heart failure and an active order for digoxin did not have a required digoxin level obtained for over a year, despite a pharmacist's recommendation and an existing physician order for monitoring every six months. The omission was only identified after a surveyor's request, and staff confirmed the lapse in following the monitoring order.
Staff failed to follow established safety practices by transporting a resident in a wheelchair without foot pedals on multiple occasions, despite the resident's medical conditions and facility expectations. Additionally, the facility did not adequately monitor a resident known for pocketing food during meals.
The facility did not maintain complete medical records for two residents, as pharmacist recommendations regarding medication irregularities were missing from their electronic health records. In both cases, the recommendations were either not entered, only available in the pharmacy's system, or not yet uploaded, resulting in incomplete documentation and a failure to meet regulatory requirements.
Surveyors found multiple environmental deficiencies, including unclean spa rooms with bowel movements left in commodes, missing shower tiles, exposed clean linens on open wire shelving, and accumulated dust and debris under equipment and carts. The Maintenance Director was unaware of several of these issues.
A resident with severe cognitive impairment and dysphagia was repeatedly left unsupervised during meals, provided only a single bowl of pureed food and a plastic spoon without a beverage, and struggled to self-feed, resulting in food spillage and prolonged chewing without staff intervention. Staff failed to monitor or assist the resident despite her known history of food pocketing and difficulty eating, and care documentation did not accurately reflect care conferences with the resident's family.
A missing ceiling tile was observed above the door entering the dining area in Terrace Hall, which compromised the maintenance and testing requirements for the automatic sprinkler system as required by NFPA 25. This deficiency was confirmed by the Maintenance Director during inspection.
Surveyors found that delayed egress double doors at the south end lacked the required 15-second delayed egress sign, as confirmed by the Maintenance Director. This failure to properly identify the door as a delayed egress door did not meet regulatory requirements and could impact emergency exiting for 35 occupants.
A battery charger for a wheelchair was found in use within a resident's room, with the battery being recharged overnight while the resident was present. The room did not have the required fire barrier or automatic fire extinguishing system, as confirmed by the Maintenance Director during observation and interview.
Two employees were observed smoking outside on campus grounds at a picnic table near the building, contrary to the facility's policy that only allows smoking inside vehicles. This was confirmed by policy review and interview with the Maintenance Director, indicating a failure to enforce required smoking regulations.
A resident with dementia and mental health issues was involuntarily discharged to a hospital without proper notification or documentation. The facility failed to inform the resident's guardian and the local Ombudsman, resulting in the resident remaining in the hospital without a clear plan for return or alternative placement.
A resident with dementia and mental health issues was sent to the hospital for aggressive behavior and was not allowed to return to the facility, violating the bed-hold policy. The facility failed to complete necessary discharge paperwork or initiate involuntary discharge procedures, leaving the resident without a home to return to.
A medication cart was left unlocked and unattended in a hallway, compromising the security of controlled substances stored within. An RN acknowledged the oversight, citing a delay in the oncoming nurse's arrival. Interviews with staff confirmed the expectation to lock carts when unattended, aligning with facility policies requiring double lock security for controlled substances.
A facility failed to protect a resident's medical records, leaving an e-MAR visible on a medication cart without staff supervision. Staff interviews revealed inconsistent practices in securing computer screens, with some relying on ineffective methods. The DON confirmed the expectation to hide screens, aligning with the facility's HIPAA policy.
A resident with dementia and depression exhibited increased agitation and combative behaviors after abrupt discontinuation of Zyprexa. The facility failed to update the care plan or implement new interventions, leading to physical aggression towards staff and other residents. Another resident was physically assaulted, but due to insufficient supervision and lack of reliable witnesses, the incident could not be verified. The facility's inaction and lack of documentation contributed to the deficiency in protecting residents from abuse.
A resident with severe cognitive impairment was left unsupervised outside a facility for approximately three hours while waiting for a day center bus that never picked her up. The resident, who was not recommended for outdoor independence, was observed by multiple staff members but was not assessed or assisted back inside. The incident was not reported until nine days later, highlighting a lack of supervision and communication among staff.
A resident with a history of aggressive behavior pushed another resident, resulting in fractures to her right radius and femoral neck. The incident occurred in a dining area, and the aggressive resident admitted to acting out to leave the facility. The injured resident, who was severely cognitively impaired, required hospitalization for her injuries.
The facility failed to properly assess, monitor, and treat pressure ulcers for three residents, resulting in significant deterioration of their conditions. One resident's wounds worsened due to inadequate repositioning and lack of communication, another experienced progression of wounds due to inconsistent care and delayed treatment, and a third developed new unstageable pressure ulcers without prompt treatment or proper documentation.
The facility failed to follow standards of care for five residents, leading to unaddressed medical concerns, incomplete wound care treatments, improper medication administration, and inadequate post-fall neurological assessments. These deficiencies were identified by surveyors and involved multiple residents with chronic conditions and cognitive impairments.
A resident with multiple diagnoses, including COPD and muscle weakness, was moved from her room of three years following an incident with her roommate. Despite expressing a strong desire to return to her original room, the facility did not accommodate her request, leading to feelings of frustration and distress.
The facility failed to notify responsible parties after falls for two residents, leading to delays in medical intervention and care. One resident, moderately cognitively impaired, fell unwitnessed, and another, severely cognitively impaired, was observed with extensive facial bruising. Notifications to the physician and family were not made promptly as required by facility policy.
The facility failed to implement policies for reporting a resident-to-resident incident involving two residents. One resident, with multiple health issues, reported threats and yelling from her roommate, which were not documented or addressed by the staff. The facility's response to a related complaint was inadequate, and the incident was not properly reported as per policy.
The facility failed to revise care plans for two residents, one after a fall and another with worsening pressure ulcers, despite clear indications and staff acknowledgment that updates were necessary.
A resident with difficulty in walking and muscle weakness did not receive scheduled showers on two consecutive days, leading to frustration. The staff failed to document the refusal of the shower, and the Unit Manager acknowledged the oversight.
The facility failed to prevent an elopement for a resident with severe cognitive impairments, resulting in the resident leaving the facility unnoticed and sustaining minor injuries. Additionally, the facility failed to complete post-fall assessments for another resident with extensive facial bruising, delaying necessary evaluations and notifications.
The facility failed to follow physician orders for a resident's suprapubic catheter care, including not cleansing the site with soap and water, not changing dressings, not emptying the drainage bag every shift, and not irrigating the catheter as required. The resident reported a foul odor from the catheter site, and multiple instances of missing documentation were noted in the Treatment Administration Record.
A resident with multiple health issues, including pressure ulcers and diabetes, reported receiving cold food and staff not reheating it despite requests. The Dietary Manager was aware of the complaint but had not followed up, leaving the issue unresolved.
The facility failed to ensure that a resident with a left above-the-knee amputation received necessary follow-up appointments and adjustments for his prosthetic leg, resulting in pain and frustration. Despite the resident's complaints and the physical therapy plan indicating the need for adjustments and staff assistance, there was no evidence that the facility staff were trained to assist the resident with the prosthetic leg or that the resident's guardian was involved in the therapy plan of care.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks for their care. Incidents involving altercations, rough transfers, and threats were not properly documented, compromising the residents' safety and well-being.
A facility failed to maintain clean medical equipment at the bedside for a resident with a feeding tube, resulting in the potential use of unsanitary devices. Despite acknowledging the issue, the DON did not remove the unclean items, which remained at the bedside during subsequent observations.
The facility failed to ensure that the designated Infection Preventionist (IP) completed specialized training in infection prevention and control before assuming the role. The current IP, an RN Unit Manager, had taken over the role a few months ago and was still in the process of completing her IP certificate, having not yet taken the final test for certification.
Failure to Schedule and Maintain Post-Op Orthopedic Follow-Up Appointment
Penalty
Summary
The facility failed to ensure services were provided according to professional standards of practice when staff did not arrange a scheduled post-operative orthopedic follow-up appointment for one resident. The resident was admitted with diagnoses including orthopedic aftercare and dementia, and the local hospital’s After Visit Summary dated 12/3/2025 documented a post-op visit with an orthopedic specialist scheduled for 12/12/2025 at 1:45 PM. The resident’s significant other later reported concern that this follow-up appointment had been missed, which was documented in the Interdisciplinary Documentation on 12/12/2025, noting that the orthopedic office would need to be contacted and a new post-op follow-up appointment made. Further review of the resident’s record showed that the follow-up orthopedic visit did not occur until 12/24/2025. The Medical Records Manager stated that she had been on leave at the time of the resident’s admission and that another staff member was covering her duties. She reported that the After Visit Summary should have been reviewed at admission and necessary follow-up appointments scheduled, but her logs contained no documentation that the post-op appointment was noted or scheduled at that time. The DON reported being uncertain why the resident missed the original post-op appointment and was unable to find documentation explaining how it was missed.
Failure to Prevent and Manage Pressure Ulcer Due to Inconsistent Pressure Relief and Documentation
Penalty
Summary
A deficiency was identified when a resident with multiple risk factors, including diabetes mellitus, muscle weakness, muscle wasting, abnormal posture, and dementia, developed a stage 3 pressure ulcer on the left heel. The resident was largely immobile, unable to move his neck upright, and could only move his right arm and hand. During care observations, staff elevated the resident's left foot on a pillow but did not use any other pressure-relieving device for the foot, despite a pressure-relieving boot being available at the bedside. The resident's specialty air mattress was found set on 'firm,' and staff were unaware of the correct settings for the mattress or how to adjust it appropriately. The facility did not provide the mattress manual or clarify the correct settings when requested by the surveyor. The DON confirmed the pressure ulcer was facility-acquired and could not identify the cause. There was no documentation or process in place to determine the cause of the pressure ulcer, and the facility's policy did not address this. The care plan noted the resident sometimes refused care, but there was no documentation of refusals related to pressure relief prior to the ulcer's development, nor any evidence of communication with the resident's guardian or brother regarding refusals. The care plan included interventions such as using an alternating pressure mattress and a pressure-relieving boot, but these were not consistently implemented or documented as refused. Additionally, staff did not have clear expectations or documentation practices for reapproaching the resident after refusals or for involving the guardian or family members to assist with compliance. The lack of consistent use of pressure-relieving devices, unclear mattress settings, and insufficient documentation and communication regarding care refusals contributed to the resident developing a stage 3 pressure ulcer.
Plan Of Correction
ELEMENT #1: ACTION TAKEN: Resident #26 will have a review of positioning devices, and the alternating pressure mattress will be set per manufacturer guidelines. The resident person-centered plan of care will be reviewed to ensure interventions are in place and utilized to promote wound healing and prevent further pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #2: IDENTIFICATION OF OTHER RESIDENTS: Residents residing at Lake Woods have the potential to be affected. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote wound healing and prevent pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #3: MEASURES TAKEN: Lake Woods will provide reeducation to licensed nursing staff and certified nursing assistants by 5/26/2025 prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include application of person-centered interventions, with examples provided of various interventions for utilization to prevent worsening or the development of pressure injuries. The education will include the location of the resident's preference of settings for their alternating pressure mattress to ensure it is followed. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designee will conduct rounds 3-5 times per week for 4 weeks on varying shifts to evaluate the education provided and inspect for the implementation of care planned interventions, including a review of the alternating pressure mattress settings, to prevent worsening or the development of pressure injuries. The Director of Health Care Services will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustained compliance.
Failure to Maintain Water Management Program and Routine Flushing
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. During a facility tour, surveyors observed multiple instances of discolored water and lack of regular flushing in various areas, including soiled utility rooms, spa rooms, janitor sinks, and the laundry room. In several locations, water from fixtures was brown or black before running clear, and some fixtures had not been flushed for extended periods, as evidenced by evaporated water in a commode basin and dust accumulation on unused shower equipment. Maintenance staff confirmed that flushing was not routinely performed in these areas, with a focus only on vacant rooms. Further interviews with maintenance and facility directors revealed that the facility's water management practices were insufficient. Annual testing for free chlorine was only conducted on cold water samples, with no testing performed on the hot water systems that service residents. Additionally, a review of the facility's own risk assessment document indicated that regular flushing of low-flow pipe runs and infrequently used fixtures was required, but this was not being implemented. No specific residents or staff were identified as directly affected in the report.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: The facility will conduct a review of the plan to reduce the risk of legionella and other opportunistic pathogens of premise plumbing. An audit will be completed by 5/26/2025 of hot and cold water fixtures regardless of room vacancy. Fixtures that have not been flushed will be at that time, including the one in the soiled utility room near the salon. The hopper and the mop sinks hot and cold water fixtures in the soiled utility room near room 40 will be flushed by 5/26/2025. The shower in the corner of the spa room will be deep cleaned by 5/26/2025 and repairs will be made to rectify the flow of water to ensure flushing of the fixture can be completed. A repair will be made by 5/26/2025 to apply the cold handle to the sink in the janitors closet, and once repaired the faucet will be flushed. The hot water faucet on the same sink will be flushed. A repair to the handle of the hot water line in the laundry room will be made by 5/26/2025, and once repaired the faucet will be flushed. The facility will complete a free chlorine test of hot water by 5/26/2025, any abnormal results will be rectified. ELEMENT 2 IDENTIFICATION OF OTHER RESIDENTS: All residents residing in the facility have the potential to be affected. All residents will be reviewed for waterborne illness. The health care practitioner will be notified of any residents identified to have signs or symptoms for further medical assessment and treatment. ELEMENT #3 MEASURES TAKEN: Members of the Water Management Committee, to include the Administrator, Director of Health Care Services, Infection Prevention, Environmental Services and Maintenance staff will be reeducated by or prior to 5/26/2025 to the next day work in the case of a leave of absence or vacationing employee related to water management plan and services to reduce the risk Legionella and other opportunistic pathogens of premise plumbing, and water quality measures and disinfectant residual practices. ELEMENT #4 MONITORING: The Nursing Home Administrator and or designee will conduct an audit through observation of Environmental Services and or Maintenance staff flushing faucets throughout the facility, regardless of room vacancy 3-5 times a week for four weeks and periodically thereafter. The water management plan will be reviewed under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Administrator, or designee(s), will audit as adherence to the policy and procedure to prevent Legionnaires Disease potential sources weekly for four (4) weeks. A summary report of the findings will be provided to the QAPI Program/Committee for review. The Administrator will assume responsibility for attained and sustained compliance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents' rights to be free from physical abuse. One resident with severe dementia and a history of wandering entered another resident's room and mistakenly got into his bed. The second resident, also severely cognitively impaired, was observed by staff with his hands on the first resident's shoulders and then making contact with an open hand to the side of her face. Witness statements from staff and a housekeeper confirmed that the second resident pinned the first resident to the bed and slapped her on both sides of her face before staff intervened. The first resident was upset but did not sustain visible injuries. Prior to this incident, the first resident had a documented history of wandering into other residents' rooms and had previously been involved in another physical altercation after entering a different resident's room. Interventions such as 15-minute checks and a companion during evening hours had been implemented due to her increased confusion and wandering behaviors. Despite these measures, the resident was able to enter another resident's room unsupervised, leading to the physical abuse incident. Both residents involved were severely cognitively impaired, with documented diagnoses of dementia and other neurological conditions. The first resident's care plan noted altered mobility, poor safety awareness, and a need for redirection due to wandering. The second resident had no recall of the incident and was also noted to be confused. The failure to adequately supervise and prevent the first resident from entering other residents' rooms resulted in a situation where she was physically abused by another resident.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #58 and Resident #60 will have a review of the person-centered plan of care review to mitigate further resident to resident interactions. ELEMENT #2: Identification of Other residents: Lake Woods strives to establish clinical and psychological support practices for our residents that limit the opportunity for avoidable interactions. Residents residing in the facility that are identified as having wandering behavior will be identified through a review of MDS section E0900 and will have a review to their person-centered plan of care interventions to mitigate risk of avoidable resident to resident occurrences. Root cause analysis will be completed, and any opportunities that are identified will be care planned. ELEMENT #3: Systemic Changes: Lake Woods will consistently follow Policies and Procedures Protecting our residents from abuse and mistreatment. All staff will be reeducated by 5/26/2025 or prior to their next day worked in the event of a leave of absence or vacationing employee, regarding the abuse and neglect protocols. Specific examples of possible interventions will be included in the education that may reduce the risk of other resident to resident interactions from occurring. The reeducation will include an Abuse prevention overview including a review of policies entitled; Abuse Suspected Abuse Investigations; Abuse Prevention Overview; and Resident to Resident Interactions. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will review the implementation of interventions to mitigate the risk of an avoidable event 3-5 times a week for four weeks enquiring with staff to evaluate understanding and implementation of interventions to prevent high risk events. The Director of Health Care Services or designee will provide a report to QAPI for one (1) month. The Administrator assumes responsibility for attained and sustained compliance.
Failure to Obtain Timely Digoxin Level per Physician Order
Penalty
Summary
A 79-year-old resident with diagnoses including congestive heart failure and osteoarthritis was admitted to the facility and had an active physician's order for digoxin 125 mcg daily, along with an order for a digoxin level to be obtained every six months. The pharmacist's medication regimen review on 4/3/25 noted that the last digoxin level was obtained on 4/12/24 and recommended that a new level be obtained immediately and then every six months thereafter, due to the medication's narrow therapeutic window. However, a review of the resident's medical record from 4/12/24 to 5/1/25 revealed no evidence that a digoxin level had been obtained or ordered in response to the pharmacist's recommendation. When the surveyor requested documentation of the digoxin level or an order for it, it was discovered that the order was only written after the surveyor's inquiry. Interviews with clinical staff confirmed that the digoxin level had not been ordered as recommended, despite other laboratory recommendations from the same pharmacy review being followed. The DON also confirmed that the last digoxin level was obtained over a year prior and could not explain why the six-month interval order was not followed.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #36 had a Digoxin lab level drawn on 5-13-2025. ELEMENT #2: Identification of Other residents who may have the potential to be affected: All residents residing at the facility that receive Digoxin have the potential to be affected and will be identified through an order listing report. An audit will be completed to validate a lab has been completed as ordered. Any discrepancies identified will be reviewed with the health care provider. ELEMENT #3: Systemic Changes: Licensed Nursing Staff will be reeducated by 5/26/2025 or prior to their next date worked in the case of the leave of absence or vacationing employee, regarding expectations of following a physician order. Education will include a review of pharmacy recommendations and the facilities process of reviewing them with the provider, the process of ordering labs per provider orders based on the recommendation, and ensuring the labs are completed. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will audit medical records with individuals who had pharmacy recommendations to complete labs 3-5 times per week for 4 weeks to verify the labs were completed based on the physician orders. The Director of Health Care Services will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Director of Health Care Service will assume responsibility for attained and sustained compliance.
Failure to Ensure Safe Wheelchair Transport and Resident Monitoring
Penalty
Summary
The facility failed to prevent accident hazards by not ensuring safe transportation of a resident in a wheelchair and by not adequately monitoring another resident known for pocketing food. Specifically, a 61-year-old resident with multiple diagnoses including unsteadiness, difficulty walking, dementia, and muscle weakness was observed being pushed in a wheelchair without foot pedals by staff on two separate occasions. The resident's care plan indicated that staff could assist with wheelchair propulsion as needed, and facility staff interviews confirmed that the standard practice is to use foot pedals when pushing residents in wheelchairs. However, both direct observation and staff statements revealed that this protocol was not followed, and the facility did not have a written policy addressing this issue, relying instead on orientation materials and standard practice. Additionally, the report notes that the facility failed to monitor a resident known for pocketing food during meals, though the detailed findings focus primarily on the wheelchair transport issue. Staff interviews and a review of orientation materials confirmed that the expectation is 'No Pedals, No Push,' yet this was not adhered to in practice. The lack of a formal written policy and repeated non-compliance with established safety practices contributed to the deficiency.
Plan Of Correction
Element #1 ACTION TAKEN: Resident #34 will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. Wheelchair foot pedals were provided to Resident #34. Resident #42 will have a review of their person-centered plan of care to ensure safe monitoring is provided during meals and reflected on the plan of care with revisions made based on the review. Element #2 IDENTIFICATION OF OTHER RESIDENTS: Residents residing at the facility requiring assistance for wheelchair mobility have the potential to be affected and will be identified through the care plan item listing report for locomotion. Identified residents will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. An audit will be conducted to validate residents requiring assistance for wheelchair mobility have foot pedals available for use. Residents that pocket food have the potential to be affected and will be identified through care plan review. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote safety monitoring during meals. ELEMENT #3: SYSTEMIC CHANGES: Lake Woods will provide reeducation to all staff by 5/26/2025 or prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include the standard of practice while providing locomotion assistance in the wheelchair with the utilization of the foot pedals. Licensed nursing staff and certified nursing assistants will receive reeducation that residents who pocket food require supervision at meals, and the importance of offering fluids during meals. Examples will be provided when residents may decline assistance and examples of interventions for staff utilization to encourage the residents to accept assistance. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designees will observe staff on various shifts as they provide assistance to residents with locomotion while in their wheelchair, including utilization of foot pedals 3-5 times a week for four weeks and periodically thereafter to evaluate effectiveness of the education that was provided. An additional observation will be completed during various mealtimes to ensure staff are providing monitoring of residents that are known to pocket food. This audit will be conducted 3-5 times a week for four weeks and periodically thereafter. The Director of Health Care Service will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustaining compliance.
Incomplete Documentation of Pharmacist Recommendations in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by federal regulations. For one resident, who had diagnoses including depression and diabetes, pharmacist medication regimen reviews identified potential medication irregularities on three separate occasions. However, the corresponding pharmacist recommendations and documentation regarding these irregularities were not present in the resident's medical record. The recommendations were either not entered, only available in the pharmacy's computer system, or awaiting upload despite being signed by the physician weeks prior. For another resident with diagnoses including congestive heart failure and osteoarthritis, a pharmacist medication regimen review also identified a potential medication irregularity. The pharmacist's recommendation related to this irregularity was not found in the resident's medical record. Although the facility was able to provide a copy of the recommendation from the pharmacy's computer system upon request, it was not included in the resident's official medical record at the time of the survey. Interviews with facility staff confirmed that the pharmacist recommendations for both residents were not present in the residents' medical records. In some cases, recommendations were only stored in the pharmacy's system or had not yet been uploaded to the electronic health record, resulting in incomplete documentation. This lack of timely and accurate recordkeeping interfered with the ability to ensure informed decisions and continuity of care for the affected residents.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: Resident #26 pharmacy recommendations from 8/6/2024, 11/4/2024, and 4/3/2025 are in the medical record. Element #2 Identification of other Residents: Each resident residing in the facility has the potential to be affected. Pharmacy recommendations conducted at the facility in the last 30 days will be completed to validate the recommendations are in the residents' medical record. Element #3 Measures Taken: Reeducation will be provided to the Director of Health Care Services and Health Information Manager by 5/26/2025 or prior to the next day worked in the /case of the leave of absence, or vacationing employee. The educational agenda will include the requirement of all pharmacy recommendations, including recommendations made to nursing, to be uploaded in the medical record in a timely manner once completed. Element #4 Monitoring Measures Taken: The Nursing Home Administrator and/or Designees will conduct an audit of medical records 3-5 times a week for four (4) weeks and periodically thereafter to ensure pharmacy recommendations, including those made to nursing, are in the medical record in a timely manner once completed. The Nursing Home Administrator will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Nursing Home Administrator will assume responsibility for attained and sustained compliance.
Environmental Deficiencies in Spa and Linen Areas
Penalty
Summary
During a facility tour with the Maintenance Director, surveyors observed several environmental deficiencies. In the spa room near the activities area, there was a strong odor and a bowel movement left in the commode, with clean folded towels stacked next to the sink. The shower floor in the same room had approximately a dozen one-inch square tiles missing near the front, and a piece of trash identified as a gold tooth filling was found on the floor. The Maintenance Director was unaware of these issues and could not identify if any resident was missing a tooth filling. In the clean linen room, the bottom rack of the linen cart was open wire shelving, leaving clean linens exposed to contamination, and there was an accumulation of trash, dust, and dirt under the cart, which was rarely moved. In another spa room at the end of the hall, a bowel movement was found in the commode and smeared on the padded cover for the plumbing under the sink, and dust was observed on unused equipment and the shower fixture.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: The spa room near the activities center was deep cleaned and the area of the floor where there were missing tiles will be repaired by 5/26/2025. The floor in the clean linen room was cleaned. A solid surface shelf was installed on the bottom shelf of the clean linen cart in the clean linen room. The spa room at the end of the hall was deep cleaned including the padding of the plumbing pipe under the sink that was also sanitized. ELEMENT 2 IDENTIFICATION OF OTHER RESIDENTS: The facility will conduct a resident council meeting by 5/26/2025 where residents will have the opportunity to express any concerns related to their living environment. Any identified concerns will be addressed through the resident grievance process. ELEMENT 3 MEASURES TAKEN: All staff will receive reeducation by or prior to 5/26/2025 or the next day worked in the case of a leave of absence or vacationing employee related to the standards of providing a safe, functional, sanitary, and comfortable environment to ensure satisfaction of the living environment is maintained for residents, staff, and visitors. ELEMENT 4 MONITORING: The Nursing Home Administrator and or designee will conduct an audit through observation during rounds in the facility 3-5 times a week for four weeks, and periodically thereafter. The observations will be of various areas and rooms throughout the facility to ensure a safe, functional, sanitary, and comfortable living environment is maintained. Examples of locations to audit are shower rooms, resident rooms, storage rooms, linen closets, dining rooms, etc. A summary report of the findings will be provided to the QAPI Program/Committee for review. The Administrator will assume responsibility for attained and sustained compliance.
Failure to Supervise and Assist Cognitively Impaired Resident During Meals
Penalty
Summary
An 84-year-old resident with severe cognitive impairment, vascular dementia with behavioral disturbance, affective mood disorder, insomnia, and dysphagia was observed during multiple lunch periods to be left unsupervised while eating. The resident, who was on a pureed diet with regular liquids and had a history of pocketing food, was provided with a single bowl of mechanically altered food and a plastic spoon, but no beverage was initially given. Staff were not present in the immediate area to monitor or assist the resident, despite her difficulties with self-feeding, including being unable to use the spoon effectively, resorting to eating with her fingers, and accumulating food on her hands, clothing, and the table. The resident was also observed chewing the same bite of food for extended periods, with staff only intervening after concerns were raised about food pocketing and lack of fluids. Documentation indicated that the resident required only setup or clean-up assistance for eating, but direct observation showed significant challenges with self-feeding and a lack of timely staff intervention. The care plan and dietary orders were not effectively implemented, as the resident was not consistently provided with beverages and was not adequately monitored for safe eating practices, despite known risks such as food pocketing. Additionally, there was a discrepancy in care conference documentation, with staff reporting that a care conference with the resident's son had not occurred as documented, raising concerns about care coordination and communication.
Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tile
Penalty
Summary
A deficiency was identified when a ceiling tile was found missing from the drop ceiling grid in Terrace Hall above the door entering the dining area. This observation was made during a facility inspection and confirmed by interview with the Maintenance Director. The missing ceiling tile compromised the maintenance and testing requirements for the automatic sprinkler system as outlined by NFPA 25, specifically impacting the system's ability to function as intended due to the absence of a heat collector in that area. The report documents that the facility failed to ensure the sprinkler system was maintained in accordance with required standards, as evidenced by this physical deficiency.
Plan Of Correction
Element #1 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. Element #2 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. A facility-wide audit was conducted to identify and replace any additional missing drop ceiling tiles. Element #3 The EVS manager and/or designee will audit twice weekly to validate there are no missing drop ceiling tiles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Missing Delayed Egress Signage on Exit Doors
Penalty
Summary
A deficiency was identified when surveyors observed that the delayed egress double doors located at the south end of the facility did not have the required 15-second delayed egress sign. This observation was made during a walkthrough and was confirmed through an interview with the facility Maintenance Director at the time of the observation. The lack of proper signage on the delayed egress doors means that the doors were not in compliance with the requirements for special locking arrangements as outlined in the applicable codes. The report specifically notes that the door was not identified as a delayed egress door, which is necessary for proper emergency exiting procedures. The deficiency could potentially affect 35 occupants in the area if emergency exiting is required.
Plan Of Correction
Element #1 Signage was added to the emergency egress door that indicates 15 second egress. Element #2 Signage was added to the emergency egress door that indicates 15 second egress. A facility-wide audit was conducted to validate all egress doors have appropriate signage. Element #3 The EVS facility manager will monitor egress doors twice weekly to assure signage remains. The EVS Manager will report findings of missing signage immediately to the Administrator. And will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Failure to Provide Fire Barrier Protection in Hazardous Area
Penalty
Summary
The facility failed to ensure that hazardous areas were protected by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system as required. Specifically, a battery charger for a wheelchair was observed in use within a resident's room located in B hall. The battery was being recharged during night hours while the resident was present in the room. This practice was confirmed through an interview with the facility Maintenance Director at the time of observation. The deficiency was identified during an observation on April 29, 2025, at approximately 11:31 AM. The report notes that the area where the battery charging occurred did not meet the required fire safety standards, as the room was not separated by the necessary fire barrier or equipped with an automatic fire extinguishing system. The finding was based on direct observation and staff interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Element #1 The power chair battery charger for room 10 was removed from the resident room and relocated to a non-resident care area for overnight charging. Element #2 The power chair battery charger for room 10 was removed from the resident room and relocated to a non-resident care area for overnight charging. A facility-wide audit was conducted to identify additional power wheelchairs that would require charging in the facility. All staff will be re-educated on the requirement for power chairs to be charged in non-resident care areas by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit twice weekly to validate power chairs are being charged in the designated, non-resident care areas. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Noncompliance with Smoking Policy by Facility Staff
Penalty
Summary
Facility staff failed to adhere to established smoking regulations as required by 19.7.4. During an observation, two employees were seen smoking outside on the campus grounds at a picnic table near the building, which was not in accordance with the facility's smoking policy that only permits smoking inside personal vehicles. This noncompliance was confirmed through a review of the facility's smoking policy and an interview with the Maintenance Director at the time of the observation. The deficiency was identified as potentially affecting 26 occupants in the event of a fire, as the required smoking regulations were not fully implemented or enforced.
Plan Of Correction
Element #1 The facility smoking policy was reviewed and acknowledges the facility will not provide a designated outdoor smoking area on facility property. Staff are permitted to smoke in their vehicle. Element #2 All staff will be re-educated on the smoke free facility policy and procedures by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit four to six times weekly to validate staff adherence to the smoke free facility policy and smoking only off premises or in their personal vehicles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee Monthly times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Failure to Notify and Document Involuntary Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the local Ombudsman about a facility-initiated discharge. The resident, a male with a history of dementia, bipolar disorder, and other mental health issues, was sent to a hospital following an incident where he exhibited aggressive behavior towards staff. Despite the transfer, the facility did not provide the necessary discharge paperwork to the resident or his guardian, nor did they inform the Ombudsman as required by their policy. The Nursing Home Administrator and Director of Nursing admitted during interviews that they did not complete the necessary transfer paperwork for the resident. They confirmed that they informed the resident's guardian via telephone that the resident was sent to the hospital and would not be allowed to return to the facility. This lack of documentation and formal notification resulted in the resident remaining in the hospital for an extended period without a clear plan for his return or alternative placement. The facility's failure to follow its own policies and procedures for involuntary discharges was further highlighted by the local Ombudsman, who was unaware of the resident's situation. The Ombudsman noted that the facility did not check the appropriate boxes on the discharge forms to indicate whether the resident would return, nor did they send the required monthly discharge list to the state. This oversight contributed to the resident's prolonged hospital stay and lack of placement options.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, a male with dementia, bipolar disorder, and other mental health issues, was sent to the hospital due to aggressive behavior, including hitting staff. Despite the resident's guardian being informed of the transfer, the facility did not complete or provide any discharge paperwork, nor did they initiate involuntary discharge procedures. This resulted in the resident being involuntarily discharged without a home to return to, as the facility refused to readmit him. The incident involved a series of actions and inactions by the facility's staff and administration. After the resident exhibited aggressive behavior, the facility's administration, including the Nursing Home Administrator and Director of Nursing, decided not to allow the resident to return. They communicated this decision to the hospital but failed to provide the necessary documentation or follow proper discharge procedures. The resident's guardian was informed via phone, but no formal paperwork was completed, leaving the resident in the hospital for an extended period without placement options.
Medication Cart Security Breach
Penalty
Summary
The facility failed to secure one of its medication carts, specifically the Harbor Medication Cart, which was observed to be left unlocked and unattended in a hallway outside a resident's room. This observation was made on the morning of October 22, 2024, at 07:55 AM. The cart's lock was visibly in the unlocked position, indicated by a red/orange dot, and there were no staff members within visual range of the cart, although residents were present in the hallway. This situation resulted in the controlled substances stored in the cart being secured by only a single lock, contrary to the requirement for a double lock system for controlled substances. During the incident, an Agency Registered Nurse (RN) returned to the cart and acknowledged the oversight, explaining that she was assisting with medication administration due to the oncoming nurse's delay. Interviews with other nursing staff, including a Licensed Practical Nurse (LPN) and another RN, confirmed that it is standard practice to lock medication carts when unattended, except in emergencies. The Director of Nursing also affirmed that nurses are expected to lock their carts when leaving them. The facility's policies on medication storage and controlled medication security, revised in 2021 and 2016 respectively, were reviewed and confirmed the requirement for medication carts to be locked or attended by authorized personnel, and for controlled substances to be stored under double lock.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for one resident, resulting in the potential for unauthorized access to personal health information. During an observation, a computer screen on the Harbor Medication Cart was left open, displaying the resident's electronic Medication Administration Record (e-MAR) with personal and health identifying information visible to passersby. No staff were present near the medication cart at the time, and an Agency RN later returned, acknowledging the oversight and explaining that she was assisting due to a staffing delay. Interviews with staff revealed inconsistent practices in securing computer screens. An LPN mentioned that she allows her computer to go to sleep when away from the cart, but acknowledged that this does not effectively hide the information if the cart is disturbed. Another RN described using a method to hide the screen, which displays a message if the mouse is moved, to protect resident privacy. The DON confirmed that nurses are expected to hide their screens when leaving the medication carts. The facility's HIPAA policy requires closing computer programs before leaving computers, indicating a failure to adhere to this policy in practice.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident #4, who was admitted with dementia and major depressive disorder, exhibited wandering and exit-seeking behaviors. Despite being on Zyprexa for depression, the medication was abruptly discontinued without proper documentation or rationale, leading to increased agitation and combative behaviors. The facility did not update Resident #4's care plan to address these changes, nor did they implement new interventions to manage his behaviors effectively. Resident #4's behaviors escalated, including physical aggression towards staff and other residents. He was observed wandering into other residents' rooms, becoming combative when redirected, and even physically assaulting a staff member. Despite these incidents, the facility did not conduct a comprehensive assessment or medication review, nor did they increase supervision or update the care plan to protect other residents. The facility's failure to address Resident #4's escalating behaviors and provide adequate supervision resulted in Resident #5 being physically assaulted by Resident #4. The facility's investigation into the incident revealed that Resident #5 had been punched by Resident #4, resulting in bruising. However, due to insufficient staff supervision and lack of reliable witnesses, the facility could not verify the incident. The facility's policy on abuse prevention was not adequately followed, as there was no increased supervision or updated care plans for behaviorally challenged residents. The facility's inaction and lack of documentation contributed to the deficiency in protecting residents from abuse.
Resident Left Unsupervised Outside for Hours
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in the resident being left unsupervised outside. The resident, who was severely cognitively impaired with a BIMS score of 6, was left outside the facility waiting for a day center bus that never picked her up. The resident was outside for approximately three hours without supervision, during which time she reported feeling hot and her scalp was warm. The resident's care plan indicated that outdoor independence was not recommended due to her cognitive and physical impairments. On the day of the incident, the resident was wheeled outside by a staff member who observed the day center bus pull into the parking lot. However, the staff member did not verify that the resident was successfully picked up before leaving for a meeting. Multiple staff members observed the resident outside but did not assess her needs or offer assistance to bring her back inside. The resident did not have access to a call light or a personal cell phone to request help, and she was not vocal about needing assistance. The incident was not reported or investigated until nine days later when the day center notified the facility after a grievance was filed by the resident's responsible party. The facility's investigation revealed that the resident was visible to staff during the time she was outside, but there was no documentation of any staff assessing her needs or offering assistance. The facility lacked policies for transportation and resident handoff, and staff education on these processes was initiated following the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident #2, who was severely cognitively impaired, was pushed by Resident #1, leading to a fall that caused fractures to her right radius and femoral neck. The incident occurred near the front lobby/dining room area when Resident #1, who was mildly cognitively impaired and had a history of aggressive behavior, pushed Resident #2 because she was in his way. Prior to the incident, Resident #1 exhibited increasing aggressive behaviors, including verbal aggression towards staff and other residents. Despite these warning signs, the facility did not effectively manage or mitigate the risk posed by Resident #1's behavior. On the day of the incident, Resident #1 was observed to be agitated and aggressive, and he admitted to pushing Resident #2 because he wanted to leave the facility. Following the incident, Resident #2 was assessed and found to have sustained significant injuries, requiring hospitalization. The facility's failure to adequately address Resident #1's escalating behaviors and protect Resident #2 from harm constitutes a deficiency in ensuring resident safety and preventing abuse.
Failure to Properly Assess, Monitor, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat pressure ulcers for three residents, resulting in significant deterioration of their conditions. Resident R48, who was admitted with multiple pressure ulcers, expressed concerns about her wounds and lack of communication from staff. Observations revealed that R48 was not repositioned adequately, and there were no positioning devices in her room. The Director of Nursing (DON) could not locate complete documentation of R48's wound sizes or stages on admission, and there was no clear plan for pressure relief or follow-up care, leading to the worsening of her wounds over time. Resident R23, admitted with a stage 2 pressure sore and other significant health issues, experienced a progression of his wounds due to inconsistent wound care and failure to implement recommended treatments. The facility did not document several dressing changes, and the recommended pressure-relieving boots were not provided in a timely manner. The DON admitted to stopping the use of the boots without proper documentation or rationale, and the wounds worsened significantly as a result. Resident R37, who had bilateral below-knee amputations and other serious health conditions, developed new unstageable pressure ulcers on his back and right thigh. Despite the resident's complaints of foul odor and lack of dressing changes, the facility failed to initiate treatment orders or a short-term care plan promptly. The wounds were not thoroughly assessed, and there was a lack of proper documentation and follow-up care, leading to the deterioration of the resident's condition.
Failure to Follow Standards of Care and Incomplete Assessments
Penalty
Summary
The facility failed to follow standards of care for five residents, leading to several deficiencies. One resident, who had chronic kidney disease and muscle weakness, complained of swollen ankles for 2-3 weeks without receiving an assessment or evaluation from her physician. Despite notifying the Nursing Home Administrator (NHA) multiple times, there was no documentation indicating that the facility addressed her concerns until the surveyor intervened. Another resident, who had idiopathic aseptic necrosis of the toes, reported that his daily dressing changes were not being performed as ordered. The Treatment Administration Record (TAR) showed multiple instances where the wound care treatments were not documented as completed, and the facility failed to provide assurance that the treatments were being administered as prescribed. Additionally, a resident with diabetes mellitus potentially experienced a serious medication error when an LPN signed out insulin that was reportedly administered by the night shift nurse, contrary to facility practice. The Director of Nursing (DON) confirmed that this practice was inconsistent with the facility's procedures. The facility also failed to complete neurological assessments for two residents after falls. One resident, who had metabolic encephalopathy and unsteadiness, experienced an unwitnessed fall, and the neurological assessments were missing documentation at several intervals. When the resident had another fall, the assessments were not restarted as required. Another resident, who had heart failure and dementia, had neurological assessments initiated after a fall, but the assessments were abruptly stopped and not completed. The facility's policy required continuous monitoring following unusual occurrences, but this was not adhered to in both cases. These deficiencies highlight significant lapses in the facility's adherence to care standards, including failure to address medical concerns promptly, incomplete wound care treatments, improper medication administration practices, and inadequate post-fall neurological assessments. These actions and inactions directly contributed to the deficiencies identified by the surveyors.
Failure to Honor Resident's Room Choice
Penalty
Summary
The facility failed to honor the resident's choice, resulting in feelings of frustration and distress for a resident. The resident, who has multiple diagnoses including Chronic Obstructive Pulmonary Disease, muscle weakness, and is on hospice, was moved from her room of three years to another room following an incident with her roommate. The resident expressed a strong desire to return to her original room, but staff did not accommodate her request, citing concerns about potential future roommates. The resident's responsible party also communicated the resident's preference to the social worker, but the resident remained in the new room against her wishes. Interviews with the resident, her responsible party, and staff revealed that the resident was initially agreeable to the temporary room change but later expressed a clear preference to return to her original room. Despite this, the facility did not facilitate the move back, leading to the resident feeling that she had to stay in the new room to avoid further trouble. The resident's belongings were still in the original room, and she expressed concerns about the potential for having a worse roommate if she returned. The facility's actions did not support the resident's right to self-determination and choice, as required by regulations.
Failure to Notify Responsible Parties After Resident Falls
Penalty
Summary
The facility failed to notify the responsible party after resident falls for two residents, resulting in the physician and family/guardian not being informed of changes in the residents' conditions. Resident #135, who was moderately cognitively impaired, fell to the floor unwitnessed on 4/23/2024, and neither the physician nor the family was notified. This was confirmed by a Corporate Consultant who acknowledged that the notifications should have been made as per the facility's policy. The facility's policy requires prompt notification of the family and healthcare practitioner following a fall with potential for injury, which was not adhered to in this case. Resident #58, who was severely cognitively impaired but independent for ambulation, was observed with extensive facial bruising on 5/13/2024. The Electronic Medical Record revealed that new bruising was noted on 5/10/2024, but the medical provider and responsible party were not notified until three days later. This delay in notification was confirmed by the Director of Nursing and Corporate Consultant, who acknowledged that the nurse did not complete the notifications as expected. The facility's policy mandates prompt notification of the medical provider and responsible party in such cases, which was not followed, leading to a delay in medical intervention and care.
Failure to Report Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement policies and procedures for reporting a resident-to-resident incident involving two residents, R7 and R26. R26, who has multiple diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Phantom Limb Syndrome, reported that R7 threatened and yelled at her in the dining room. Despite R26 informing the staff multiple times about the threats, no action was taken, and no incident was documented in R26's Electronic Medical Record (EMR) between 5/09 and 5/14/24. The facility's policy requires thorough investigation and proper reporting of any suspected abuse, neglect, or mistreatment, which was not followed in this case. R26's Responsible Party (RP) also reported that R7 was vaping in their shared room, which exacerbated R26's health issues. The RP's complaint highlighted that R7 frequently yelled at R26 and disrupted her sleep. The facility's response to the RP's complaint did not address the vaping or the verbal abuse adequately. During an interview, the NHA confirmed witnessing the incident in the dining room but did not document it in R26's record. The NHA admitted that a note should have been documented and that the residents were separated after the incident. R7, who has diagnoses including Post-Polio Syndrome, Bipolar Disorder, and Alcohol Abuse, was noted in her EMR to have been aggressive towards R26, causing R26 to cry. R7's behavior included yelling, throwing items, and being under the influence of substances. Despite these observations, the incident was not properly documented or reported in R26's records. The facility's failure to document and report the incident as per their policy resulted in a deficiency in ensuring the safety and well-being of the residents involved.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, resulting in significant oversights in their care. Resident #136, who was admitted with diagnoses including heart failure, difficulty walking, and dementia, experienced a fall on 3/15/2024. Despite the incident, no updates were made to the resident's care plan to address the increased risk of falls. Interviews with various staff members, including a corporate consultant, RN, and the Director of Nursing, confirmed that the care plan should have been updated immediately following the fall, but no such revisions were found in the resident's records. Similarly, Resident #23, who was admitted with a stage 2 pressure sore and at risk for developing additional pressure sores, did not have their care plan updated despite the development and worsening of multiple wounds. The resident's skin assessments and physician assistant documentation revealed the progression of existing wounds and the emergence of new ones, yet the comprehensive care plan remained unchanged. The short-term care plan for wound and skin issues was also not updated in a timely manner, further indicating a failure to appropriately revise the care plan in response to the resident's deteriorating condition.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide a resident with scheduled showers, resulting in the resident experiencing frustration. The resident, a [AGE] year-old male with diagnoses including difficulty in walking, muscle weakness, and a need for assistance with personal care, was scheduled to receive showers every Wednesday and Saturday evening. On 5/11/24, the resident did not receive his scheduled shower as staff claimed they did not have time, and the same occurred on 5/12/24 despite staff promising to provide the shower. The resident expressed his frustration to the Unit Manager, who acknowledged that staff are supposed to report and document any refusals of showers. However, there was no documentation in the progress notes indicating that the resident refused a shower on 5/11/24.
Failure to Prevent Elopement and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to prevent an elopement for a resident with severe cognitive impairments, resulting in the resident leaving the facility unnoticed by staff. The resident, who had a high risk of wandering, was found outside the facility in a stranger's car. The incident occurred because a staff member deactivated the exit alarm without ensuring the door was secured, allowing the resident to exit unnoticed. The resident was outside for over an hour before being found and returned to the facility, during which time he sustained minor injuries. Additionally, the facility failed to complete post-fall assessments for another resident who was found with extensive facial bruising. The resident, who was severely cognitively impaired, had an unwitnessed fall, and the initial assessment did not include a neurological evaluation or a fall assessment. The incident was not documented properly, and the medical provider and responsible party were not notified until three days later. The delay in initiating the required assessments and notifications indicated a failure in shift-to-shift reporting and adherence to facility policies. The deficiencies highlight significant lapses in the facility's supervision and response protocols, particularly in monitoring residents with cognitive impairments and ensuring timely and appropriate post-fall assessments. These failures could have led to serious physical outcomes for the residents involved.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for the care and management of a resident's suprapubic catheter. The resident, who was cognitively intact and had a history of bilateral below the knee amputations, traumatic brain injury, heart failure, and neuromuscular dysfunction of the bladder, reported that staff were not changing his dressings as required. During an observation, an LPN was seen using a partially open pack of gauze moistened with Normal Saline instead of cleansing the area with soap and water as per the physician's orders. The Treatment Administration Record (TAR) indicated that the catheter site should be cleansed with soap and water and covered with a drain sponge every evening shift, but this was not consistently documented as done on several days in April and May 2024. Additionally, the TAR showed that the catheter drainage bag was not emptied and recorded every shift as required, with multiple instances of missing documentation in April 2024. Furthermore, the order to irrigate the catheter with Acetic Acid Irrigation Solution was not marked as completed on several AM shifts in April and May 2024, with no corresponding progress notes explaining the omissions. The resident also reported a foul odor coming from the catheter site, indicating potential issues with infection control. The lack of adherence to the prescribed catheter care regimen, including the failure to cleanse the site with soap and water, change dressings, empty the drainage bag, and irrigate the catheter as ordered, highlights significant lapses in the facility's catheter care and management practices. These deficiencies were observed and documented by surveyors, confirming the facility's failure to provide appropriate catheter care for the resident.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to provide palatable food for a resident, resulting in the potential for poor nutrition and poor wound healing. The resident, a [AGE] year-old female with multiple diagnoses including pressure ulcers, diabetes mellitus, and lymphedema, expressed concerns about receiving cold food. Despite informing staff, the resident reported that they did not have time to reheat her food, leading her to leave meals uneaten. The Dietary Manager acknowledged the complaint and had completed a resident concern form but had not followed up with the resident. The issue remained unresolved as staff continued to neglect reheating the resident's food upon request.
Failure to Ensure Follow-Up and Assistance with Prosthetic Leg
Penalty
Summary
The facility failed to ensure that a resident with a left above-the-knee amputation received necessary follow-up appointments and adjustments for his prosthetic leg, resulting in pain and frustration. The resident expressed that the prosthetic leg caused discomfort and that he stopped using it because it hurt. Despite the resident's complaints and the physical therapy plan indicating the need for adjustments and staff assistance, there was no evidence that the facility staff were trained to assist the resident with the prosthetic leg or that the resident's guardian was involved in the therapy plan of care. The resident's therapy was discontinued at his request without any documented reason or involvement of his guardian to advocate for him. The Director of Nursing (DON) acknowledged that the resident had a follow-up appointment scheduled for adjustments, but the facility failed to provide transportation for the appointment. The DON attempted to reschedule the appointment but did not provide any additional information on whether the resident should continue using the prosthetic leg or receive further adjustments. The resident's legal guardian was not aware of the ongoing issues with the prosthetic leg and expressed willingness to assist the facility in addressing the resident's needs. The lack of follow-up and staff training led to the resident's pain and frustration with the use of his prosthetic leg.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in the potential for providers not having an accurate and complete picture of the residents' stay. For Resident 137, the facility's investigative documentation for an incident on 2/8/24 revealed that a CNA found Resident 137 with an open area on his eyebrow after an altercation with another resident. However, the incident was not documented in Resident 137's medical record, and the progress notes did not mention the possible cause of the laceration. Additionally, the Skin Assessment form did not indicate the reason for the assessment, whether it was routine or post-incident. Interviews with LPNs and the NHA confirmed that all incidents should be documented in the resident's medical record, but this was not done in this case. For Resident 5, the facility failed to document concerns raised by the resident about rough transfers and being molested by another resident. Despite the resident's complaints and a facility-reported incident on 5/13/24, there were no progress notes documenting these concerns on that date. The progress notes for 5/14/24 mentioned multiple concerns that met criteria for reporting to the State Agency but did not specify the actual concerns. This lack of documentation could lead to a failure in addressing the resident's safety and well-being. For Resident 26, the facility did not document an incident where the resident's roommate threatened and yelled at her in the dining room. The resident was relocated to another room for the night, but there was no documentation of the incident in the resident's Electronic Medical Record (EMR) between 5/09 and 5/14/24. Interviews with the resident, her responsible party, and the NHA confirmed the incident occurred, but it was not documented as required. This failure to document incidents accurately and completely could compromise the resident's safety and care.
Failure to Maintain Clean Medical Equipment at Bedside
Penalty
Summary
The facility failed to maintain clean and sanitary medical equipment at the bedside for one resident, resulting in the potential use of an unsanitary medical device. The resident, who has a feeding tube and receives 26 to 50% of their total calories through it, was found with a graduated vessel and a large syringe on the nightstand next to their bed. The vessel, dated 3/30/24, contained a sticky substance, and the undated syringe had an off-white substance in the barrel and tip, indicating it had not been cleaned after the last use. Despite acknowledging that the unclean medical equipment should have been discarded, the Director of Nursing did not remove these items, and they remained at the bedside during subsequent observations on 5/14/23 and 5/16/24.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed specialized training in infection prevention and control before assuming the role. According to the Centers for Medicare and Medicaid Services (CMS) Infection Prevention, Control & Immunizations pathway, the IP is required to complete this training prior to taking on the responsibilities. During an interview, the Director of Nursing (DON) confirmed that there was no employee with the required specialized training. The current IP, a Registered Nurse (RN) Unit Manager, had taken over the role a few months ago and was still in the process of completing her IP certificate, having not yet taken the final test for certification.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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