Lakeside Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 13990 Lakeside Circle, Sterling Heights, Michigan 48313
- CMS Provider Number
- 235719
- Inspections on file
- 35
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Lakeside Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with intact cognition and a history of Schizoaffective Disorder and Alzheimer's repeatedly reported discomfort and inadequate coverage due to being provided with incontinence briefs that were too small. Despite informing staff and the availability of larger briefs in the facility, the resident's preference was not honored, resulting in ongoing discomfort and improper fit. The DON acknowledged the issue and the presence of bariatric briefs, but the resident continued to receive briefs that did not meet their needs.
The facility failed to administer Heparin as ordered for a resident, did not follow hospital discharge instructions for catheter removal and bladder scans for another, and did not complete required vital sign monitoring for a third resident. These deficiencies were due to medication unavailability, overlooked discharge orders, broken equipment, and incorrect order entry in the electronic medical record.
A facility failed to prevent verbal abuse by a CNA towards a resident, leading to feelings of disrespect. The incident began when the CNA insisted on giving the resident a shower despite their refusal, escalating into a verbal altercation with threatening language. The resident, with a traumatic brain injury and multiple fractures, felt disrespected by comments related to their wheelchair use. The CNA resigned after the incident was reported to the administrator.
A facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, identified by an LPN. Despite documentation of the wound, no physician or medical staff was contacted for treatment orders, and the resident's MAR and TAR lacked documentation for the wound's treatment. The care plan did not address the new wound, and the Nurse Practitioner did not assess it until eight days later. The Director of Nursing confirmed the nurse should have entered the order into the record, but it was not added, resulting in potential wound deterioration.
The facility failed to maintain comfortable room temperatures, with two resident rooms recorded at 65 and 66 degrees Fahrenheit, leading to resident complaints of cold conditions. The Maintenance Supervisor was unsure of the standard for comfortable temperatures, and the Administrator acknowledged issues with heating units in the area. Facility policy requires temperatures between 71 and 81 degrees Fahrenheit.
The facility failed to provide bed hold policy notifications to three residents during hospital transfers, as required. Interviews and record reviews revealed that the responsibility for issuing these notices was unclear among staff, and the Social Service Director could not locate the necessary documentation. The residents involved had various medical conditions, and one reported not receiving a notice during an emergency transfer.
A resident with multiple medical conditions refused all medications and vital sign checks since readmission, but the facility failed to notify the physician or document these refusals as required by policy. The resident had not had vital signs recorded since August, and the attending physician was unaware of the refusals, indicating a lapse in communication and adherence to care standards.
A resident with moderately impaired cognition was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents and redirection by staff, the facility did not implement sufficient protective measures, such as separating the residents or providing continuous monitoring, to prevent the abuse.
The facility failed to maintain the carpet in a clean, sanitary, and safe condition, affecting all 58 residents. Observations showed stained, worn, and buckled carpet, with missing spots. Housekeeping staff indicated the need for deep cleaning and replacement, but lacked a floor technician. Residents expressed concerns about the carpet's dangerous condition, with one almost tripping. The DON acknowledged the issue, having tripped on the carpet themselves.
The facility has been without a full-time Activities Director for months, affecting all 58 residents. A resident and an Activities Aide confirmed the lack of activities, especially on weekends. The Regional Nursing Home Administrator acknowledged the absence and mentioned a new hire is expected soon. The facility's policy on activities did not include the role of an Activities Director.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily, as required. Staff postings showed multiple dates without RN coverage, confirmed by interviews with the scheduler and DON. The facility's staffing policy did not address RN coverage requirements.
The facility failed to post and maintain required nurse staffing information, affecting all 58 residents. During a survey, it was found that the facility did not have complete staff posting data for RNs and CNAs. Interviews with staff confirmed the absence of required postings, and the Director of Nursing was unaware of the missing logs. The facility's policy required daily posting of staffing information, but they failed to comply with this requirement.
The facility did not provide adequate meal portion sizes to meet residents' nutritional needs. The Dietary Supervisor served a small piece of baked chicken, estimated at 2 ounces, instead of the required 4 ounces. The RD confirmed the portion was insufficient, and residents reported feeling that the food portions were too small.
A facility failed to serve food at the preferred temperature, leading to dissatisfaction among residents. A resident reported the food was cold and unappealing, and observations showed staff serving meals with food cart doors open. A Registered Dietician confirmed the food was below the preferred temperature, and the facility's policy on serving hot foods was not followed.
The facility failed to serve meals on time, leading to resident dissatisfaction. Breakfast and lunch were served significantly later than the scheduled times due to insufficient kitchen staffing. Residents complained about hunger and the consistent lateness of meals.
A survey revealed multiple sanitation and food safety deficiencies in the kitchen of an LTC facility. Observations included a soiled trash can, improper thawing of pork chops, undated food items, and unsanitary conditions such as grime buildup and a mold-like substance in the ice machine. Additionally, the dish machine's temperature log was not maintained, and equipment like the ventilation hood lights and garbage grinder were non-functional.
The facility failed to manage its operations effectively, leading to deficiencies in maintaining a safe environment and equipment. The carpet in hallways remained stained and unsafe, and there was a lack of documentation and awareness regarding the mechanical lift's repair status. The Nursing Home Administrator was unavailable, leaving no documentation on these issues, and no Quality Assurance activities were documented to address them.
The facility failed to implement an active water management plan, lacking team member lists and water flow diagrams, and did not conduct required inspections. Additionally, staff did not consistently don and doff PPE for residents on enhanced barrier precautions, as observed in multiple instances. Interviews revealed a lack of awareness and adherence to infection control protocols, increasing the risk of infections.
The facility failed to respond promptly to call lights for four residents, resulting in significant delays in care. One resident waited over 13 minutes for pain medication, while another experienced prolonged waits in soiled conditions. A third resident reported waiting up to an hour and a half for hygiene assistance, and a fourth resident's call light was ignored for 30 minutes despite needing help with a mechanical lift. The facility lacked documentation on call light response times, and staff did not adhere to the policy requiring prompt response to call lights.
The facility failed to provide adequate activities for four residents, leading to dissatisfaction and boredom. One resident expressed having nothing to do but ride in circles in their wheelchair, while another wandered the facility seeking bird-watching opportunities. A third resident reported a lack of engagement in activities for months, and a fourth noted the absence of an activities director and weekend activities. The Activities Aide confirmed working alone during weekdays without weekend coverage, highlighting staffing and scheduling challenges.
A facility failed to maintain essential equipment, leading to safety hazards and discomfort for residents. One resident was injured by a damaged wheelchair, while another faced issues with an unstable mechanical lift and ill-fitting wheelchair cushions. Additional maintenance oversights included a broken dresser and inadequate shower pressure, highlighting a lack of attention to resident needs and safety.
The facility failed to provide a mechanical lift for two residents, leading to unsafe conditions. One resident, with muscular dystrophy, was unable to get out of bed for days, requiring fire department assistance. Another resident, with cerebral infarction, faced manual lifting by staff, which was dangerous. Staff interviews revealed a lack of documentation and awareness about the lift's repair status.
A facility failed to report an abuse allegation involving a resident attempting to touch another resident inappropriately. The incident was observed by staff but was reported to the State Agency 14 days later due to the administrator's absence and the DON's uncertainty about the reporting process. Facility policy requires immediate reporting, but this was not followed.
The facility did not provide the necessary written transfer notification to a resident and the Ombudsman when a resident was transferred to an acute care hospital due to a worsening bruise that developed into a wound. The EMR lacked documentation of the transfer notification, and the facility's administrative staff could not produce the required documentation during the survey.
A resident with respiratory issues was observed with an oxygen concentrator running but the nasal cannula was on the floor, and no active physician's order or care plan for oxygen was documented. The resident had diagnoses including Acute Respiratory Failure and COPD, and their MDS assessment indicated moderately impaired cognition. The facility's policy requires a baseline care plan, which was not implemented.
A resident with encephalopathy and type 2 diabetes experienced multiple falls without updates to their fall care plan. Despite having moderately impaired cognition and requiring supervision for ADLs, the care plan's last intervention was dated months prior. Interviews with staff confirmed the lack of updates, which contradicted the facility's policy requiring care plan revisions after status changes.
A resident in an LTC facility did not receive consistent, scheduled showers as per their preference and facility policy. Despite requiring maximal assistance with bathing due to medical conditions, the resident only received four baths in a month, with no showers documented. The resident expressed frustration over the lack of personal cleanliness, and the DON acknowledged the difficulty in accommodating the resident's preferred shower time.
The facility failed to schedule follow-up appointments for a resident with a fracture and hip replacement, leading to missed chemotherapy treatments. Additionally, another resident with respiratory issues had no active physician orders for oxygen, despite being observed with an oxygen concentrator running and reporting difficulty breathing.
A resident with limited range of motion and mobility needs did not receive restorative services as per physician orders. Despite having a care plan for restorative therapy, there was no documentation of participation in the program. The resident, who was cognitively intact and experienced occasional pain, expressed a desire for exercise to maintain and improve mobility. The Director of Nursing was unaware of the issue, and the facility's policy on providing restorative programs was not followed.
The facility did not ensure a timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. Despite pharmacy progress notes indicating irregularities, the complete MRR and physician follow-up were unavailable. The DON suggested the MRRs might be in a binder, but they were not provided, and a policy for MRRs was not received before the survey ended.
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. One resident with anxiety and rheumatoid arthritis had Alprazolam orders without a stop date, while another nonverbal resident with severe cognitive impairment had a Xanax order without a stop date. The facility's policy requiring a 14-day limit on PRN orders was not followed.
Failure to Honor Resident's Incontinence Brief Size Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for incontinence brief size, despite repeated requests and clear evidence that the provided briefs were too small and uncomfortable. The resident, who had diagnoses of Schizoaffective Disorder and Alzheimer's but was cognitively intact, reported that the briefs did not cover the thigh or buttocks area, were too tight, and caused discomfort. The resident stated they had informed staff about the issue, but was told that the current size was all that was available. Observations confirmed that the briefs were stretched thin and did not fit properly, and the resident continued to be placed in briefs that were too small over several days. Further review of the facility's supply showed that larger briefs were available in the storage room, but the correct size was not provided to the resident. The Director of Nursing acknowledged the existence of bariatric briefs for larger residents and noted that shipments had been delayed, but staff had purchased appropriate sizes as needed. The resident's care plan documented the need for assistance with incontinence care, and the facility's admission contract guaranteed reasonable accommodation of resident needs and preferences. Despite this, the resident's preference for a larger brief was not honored, resulting in discomfort and inadequate care.
Failure to Follow Physician Orders for Medication, Catheter Care, and Vital Signs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of traumatic secondary hemorrhage, seroma, and high cholesterol, Heparin doses were missed on 18 occasions due to the medication being unavailable. Documentation showed that staff did not notify the physician of the missed anticoagulant doses, as required by facility policy. The resident reported that the facility frequently ran out of Heparin, and the Director of Nursing (DON) confirmed the missed doses and lack of physician notification. Another resident, admitted with urinary retention and nephritis, was re-admitted after a hospital stay for a urinary tract infection. Hospital discharge instructions required discontinuation of an indwelling catheter and a trial of voiding with bladder scans and specific documentation. These orders were not followed, as the catheter was not discontinued, bladder scans were not performed, and there was no documentation of the required procedures. The DON and a registered nurse acknowledged that the discharge orders were overlooked, and it was revealed that the facility's bladder scan machine had been broken for months. A third resident had physician orders for regular vital sign monitoring, which were not completed as required. The electronic medical record did not prompt staff to take vital signs due to incorrect order entry, and the last recorded vitals were from the resident's admission several months prior. Staff confirmed that vital signs were not taken as ordered, and the DON stated that vital signs should be completed per physician orders and on admission for baseline.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member towards a resident, resulting in the resident feeling disrespected. The incident involved a verbal altercation between a Certified Nurse Assistant (CNA) and a resident, where the CNA insisted on giving the resident a shower despite the resident's refusal. The situation escalated when the CNA used threatening language, implying harm, which was witnessed by another staff member. The resident, who had a traumatic brain injury and multiple bone fractures, reported feeling disrespected by the CNA's comments, particularly those related to their use of a wheelchair. The incident was reported to the facility's administrator, who confirmed the details of the altercation and the threatening language used by the CNA. The CNA voluntarily resigned after suspecting termination. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury or intimidation, which includes verbal abuse. The report highlights the failure of the facility to protect the resident from verbal abuse, as required by their policy.
Failure to Timely Initiate Wound Care Orders
Penalty
Summary
The facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, which was identified on 01/07/2025. Despite the wound being noticed and documented by an LPN, there was no indication that the physician or medical staff was contacted for wound care treatment orders. The resident's Medication Administration Record (MAR) and Treatment Administration Records (TAR) did not show any documentation for treatment of the left baby toe or foot. The resident's care plan also did not address the new wound, and the Nurse Practitioner did not document an assessment of the left baby toe or foot until 01/15/2025, eight days after the wound was first identified. The Director of Nursing confirmed that the nurse should have entered the order into the record, but no order or treatment was added into the physician orders or onto the January MAR or TAR. The facility's policy requires accurate documentation of wound assessments and treatments, but this was not followed in this case. The lack of timely treatment and documentation resulted in the potential for wound deterioration, as the wound care orders were not initiated until after the resident was seen by the wound care Nurse Practitioner on 01/15/2025.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures in two resident rooms, resulting in resident complaints of cold conditions. On the morning of January 21, 2025, the air temperature in one resident's room was measured at 66 degrees Fahrenheit, and the resident was observed in bed with a blanket pulled over his head. Another resident's room was measured at 65 degrees Fahrenheit, and the resident expressed feeling cold. A nearby vacant room was found to have a temperature of 48 degrees Fahrenheit. During an interview, the Maintenance Supervisor was uncertain about the facility's standard for comfortable ambient air temperature, initially suggesting anything under 60 degrees was too low, then reconsidering to under 70 degrees, but ultimately was unsure. The Administrator was unaware of the issues in one of the rooms but acknowledged that the other room was in an area with vacant rooms and broken heating units. The facility's policy stated that temperatures in common resident areas should be maintained between 71 and 81 degrees Fahrenheit.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a bed hold policy notification for three residents during their transfer to a hospital, as required by regulations. The deficiency was identified through interviews and record reviews, which revealed that the facility did not issue written notices specifying the duration of the bed-hold policy to the residents or their representatives. The Director of Nursing stated that the responsibility for bed holds lies with the Business Office and Social Work, while the Nursing Home Administrator indicated that nurses should provide the bed hold policy upon the resident's departure, or communicate it by phone the next day in emergency situations. However, the Social Service Director, who recently assumed the role of contacting families for bed holds, was unable to locate the bed hold notice for one of the residents. The residents involved in this deficiency included one with altered mental status and metabolic encephalopathy, another with muscular dystrophy, chronic kidney disease, and high blood pressure, and a third with diabetes and high blood pressure. The records showed that these residents were transferred to the hospital for various medical reasons, but there was no documentation of bed hold notifications being provided. One resident, who was transferred in an emergency, reported not receiving a bed hold notice. The facility's policy requires that a written notice be given at the time of transfer, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Notify Physician of Resident's Refusal of Care
Penalty
Summary
The facility failed to notify the physician of a resident's refusal of vital signs and medication, which is a deficiency in meeting professional standards of quality. The resident, identified as R904, was observed in bed and appeared pleasant and conversant, with no signs of distress. R904 had a history of multiple medical conditions, including muscular dystrophy, chronic kidney disease, and diabetes mellitus, and was dependent on staff for various activities of daily living. Despite these needs, the facility did not record any vital signs for R904 since August 17, 2023, and failed to take vital signs upon the resident's readmission on September 3, 2024. The facility's records indicated that R904 had refused all medications since readmission and frequently refused care, medications, and treatments since July 8, 2023. The attending physician was not informed of these refusals, as evidenced by the lack of documentation in the physician's progress notes. The Director of Nursing confirmed that the facility's policy required documentation of refusals and physician notification, which was not adhered to in this case. The facility's policy on residents' rights regarding treatment and advance directives outlined specific documentation and notification procedures that were not followed, contributing to the deficiency.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with moderately impaired cognition who was sexually abused by another resident with a history of inappropriate sexual behavior. The abusive resident had been observed attempting to touch other residents inappropriately on multiple occasions prior to the incident. Despite these observations, the facility did not implement sufficient protective measures to prevent the abuse from occurring. The facility's investigation revealed that the abusive resident had been redirected multiple times by staff for inappropriate behavior, including attempts to touch other residents and staff. However, the facility did not provide adequate evidence of protective interventions to prevent further incidents. The abusive resident's room was located directly across the hall from the victim's room, and the facility failed to take timely action to separate the two residents or provide continuous monitoring to ensure the victim's safety.
Facility Fails to Maintain Safe and Clean Carpet Conditions
Penalty
Summary
The facility failed to maintain the carpet throughout the building in a clean, sanitary, and safe condition, affecting all 58 residents. Observations revealed that the carpet on the 200 unit was stained, worn, and had missing spots next to the walls. Further inspection showed large stains and buckling in some areas. Interviews with housekeeping staff indicated that the carpet needed a deep clean and replacement, but there was no floor technician available, and the owner had been informed about the issue. The Maintenance Director confirmed the lack of staff to operate the carpet cleaning machine and mentioned that replacing the carpet would be costly. Residents expressed concerns about the carpet's condition, describing it as dangerous and dirty, with buckling and unraveling in several places. One resident reported almost tripping while using a walker. The Director of Nursing acknowledged the issue, having personally experienced tripping on the carpet. A review of the facility's policy on providing a safe and homelike environment highlighted the requirement to ensure a safe physical layout that does not pose a safety risk, which the current carpet condition failed to meet.
Absence of Full-Time Activities Director
Penalty
Summary
The facility failed to employ a full-time Activities Director, a deficiency that potentially affects all 58 residents. During an interview, a resident reported that the facility has been without an Activities Director for months, resulting in a lack of activities, especially on weekends. The Regional Nursing Home Administrator confirmed the absence of an Activities Director and mentioned that a new hire is expected to start soon. An Activities Aide, who has been working alone in the activities department, corroborated this information, stating they have been in the role for the past year, both part-time and full-time, after previously serving as a receptionist and a certified nursing aide. Additionally, the facility's policy on activities did not mention the role of an Activities Director.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which is a requirement for adequate coordination of care. This deficiency was identified through a review of daily staff postings, which revealed multiple dates across January, March, June, and July where RN coverage was not provided. Interviews with the scheduler and the Director of Nursing (DON) confirmed the inconsistency in RN coverage, particularly when the DON joined in March. The facility's policy on Nurse Staffing Posting Information did not address the requirement for RN coverage, contributing to the deficiency.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to record and post necessary staffing information as required by regulatory guidance, which had the potential to affect all 58 residents. During a survey, it was found that the facility did not have staff posting data showing the number and hours of the staff working, particularly for RNs and CNAs. The survey team requested staff postings for specific periods, but the facility was unable to provide complete records. The facility's policy required daily posting of nurse staffing information, including the facility name, current date, resident census, and the total number and hours worked by nursing staff per shift. However, the facility did not consistently track or maintain these records. Interviews with facility staff, including the Unit Manager and the Regional Nursing Home Administrator, confirmed the absence of required staff postings. The Director of Nursing, who started in March 2024, was unaware of the missing logs. The facility's policy stated that nurse staffing information should be readily available and maintained for a minimum of 18 months. Despite this, the facility failed to provide complete staffing records for the requested periods, indicating a lack of compliance with their own policy and regulatory requirements.
Inadequate Meal Portion Sizes
Penalty
Summary
The facility failed to provide residents with meal portion sizes that met their nutritional needs, specifically regarding protein intake. During an observation, the Dietary Supervisor was seen preparing lunch trays with a small piece of baked chicken, approximately 2 1/2 inches by 2 1/2 inches, which was estimated to weigh around 2 ounces. This portion size was confirmed by the Registered Dietitian (RD) to be insufficient, as the diet spreadsheet indicated that a 4-ounce portion was required for a regular diet. A group of residents also reported that they felt the food portions were too small, leading to inadequate food intake.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for one resident and a group of seven confidential residents, leading to dissatisfaction during meals. On multiple occasions, a resident expressed dissatisfaction with the food, stating it was cold and unappealing, which resulted in them not eating most of it. During an observation, staff were seen serving lunch trays to residents' rooms with the food cart doors left open, which likely contributed to the food being served at inadequate temperatures. A Registered Dietician (RD) checked the temperature of a random food tray and found the baked chicken, cooked mixed vegetables, and orzo pasta to be significantly below the preferred temperature of 165 degrees Fahrenheit. The RD acknowledged the temperature issue, although they noted the chicken tasted good. The surveyor also taste-tested the meal and found it to be lukewarm, negatively impacting the food's palatability. The facility's policy on food preparation, which emphasizes serving hot foods hot, was reviewed and found to be inconsistent with the observed practices.
Delayed Meal Service and Resident Dissatisfaction
Penalty
Summary
The facility failed to serve meals in a timely manner and in accordance with the scheduled mealtimes, leading to resident dissatisfaction. The documented meal times were breakfast from 7:30 am to 8:30 am and lunch from 11:30 am to 12:30 pm. However, on the morning of July 14, 2024, kitchen staff were observed preparing to start breakfast service at 9:15 am, and breakfast trays were still being delivered at 10:30 am. Dietary Aide K attributed the delay to insufficient staffing, with only one or two staff members available to manage meal preparation and delivery. Additionally, lunch trays were observed being delivered at 3:07 pm, well past the scheduled lunch time, prompting complaints from residents about hunger and late meals. A confidential group of residents confirmed that meals were consistently served late, not aligning with the facility's documented meal times.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. A trash can near the handwashing sink was found without a liner and heavily soiled with a mold-like substance. The handwashing sink near the ice machine contained food debris and lacked paper towels. Additionally, raw pork chops were improperly thawed in a sink with water, reaching unsafe temperatures, and were left unattended for an extended period. Several food items in the kitchen's walk-in cooler and reach-in refrigerator were opened and undated, violating food safety standards. The kitchen's physical environment was also found to be unsanitary. The flooring throughout the kitchen had a heavy buildup of grime and food debris, and the dry storage room had food debris under the racks. The ventilation cover above the clean dishware rack was soiled with dust. The dish machine's temperature log had not been updated since earlier in the month, and staff were unsure how to monitor the machine for adequate sanitation. The interior lights for the ventilation hood were non-functional, and the garbage grinder was broken and full of old food, attracting gnats. The ice machine in the pantry was observed with a black mold-like substance on the interior sides of the ice bin. The Facilities Director confirmed the presence of the mold-like substance and noted that the cleaning solution used did not reach the sides of the machine. These observations indicate a failure to adhere to the 2017 FDA Food Code, which outlines necessary cleaning and maintenance practices to prevent contamination and ensure food safety.
Deficiencies in Facility Maintenance and Equipment Management
Penalty
Summary
The facility failed to effectively manage its daily operations, resulting in deficiencies related to the maintenance of the facility's environment and equipment. Specifically, the facility did not address the unsafe condition of the carpet throughout the hallways, which remained stained despite cleaning efforts. The Housekeeping/Laundry Supervisor acknowledged the need for carpet replacement and indicated that the issue had been communicated to the owner. Additionally, the facility did not maintain or timely replace resident care equipment, as evidenced by the lack of documentation and awareness regarding the mechanical lift's repair status. The Maintenance Supervisor and Director of Nursing were unable to provide details or documentation about the lift's repairs or the duration it was unavailable. The Nursing Home Administrator, who was on vacation, left the facility without documentation or information regarding the mechanical lift repairs or carpet plans. During a Quality Assurance review meeting, it was found that there were no documented QA activities related to the worn carpet or mechanical lift repairs in the Quality Assurance Binder. The facility's policy on providing a safe and homelike environment was not adhered to, as the facility failed to ensure that residents could receive care and services safely due to these unresolved issues.
Deficiencies in Water Management and PPE Use
Penalty
Summary
The facility failed to implement an active water management plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. During the survey, it was found that the Water Management binder lacked a list of team members and a water flow diagram. The policy outlined daily, weekly, and quarterly inspections, but there was no evidence of these being conducted. The kitchen dish machine had a heavy buildup of lime scale, and the dish machine log had not been completed since early July. Interviews with the Maintenance Supervisor, Director of Nursing/Infection Preventionist, and Administrator revealed a lack of involvement and awareness regarding the water management program, and no evidence of testing was provided by the end of the survey. The facility also failed to ensure proper donning and doffing of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). For three residents, staff were observed not wearing the required PPE during care activities. One resident reported that staff only wore gloves when emptying a catheter bag, and another resident stated that staff never wore gowns, only gloves. Interviews with staff, including a CNA and an LPN, confirmed the absence of PPE outside the residents' rooms and a lack of adherence to PPE protocols. The Director of Nursing stated that staff were expected to wear PPE when providing care to residents on EBP. The facility's infection prevention and control program policy, reviewed and revised in March 2024, emphasized the need for staff education and competence in resident care procedures. However, observations and interviews indicated that staff did not consistently follow the established procedures for infection control, particularly in relation to the use of PPE for residents on EBP. This failure to adhere to infection control protocols increased the risk of communicable diseases and infections among residents.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for four residents, leading to significant delays in care. Resident R50's call light was activated for over 13 minutes before being addressed, during which time they requested a pain pill. R50 reported that it sometimes takes 30 minutes to an hour for their call light to be answered. R49 expressed that it takes 20 to 30 minutes for their call light to be initially answered, and they have experienced waiting in soiled conditions for 2 to 3 hours. R49's call light logs were unavailable for review. Resident R24 reported waiting up to an hour and a half for their call light to be answered, particularly when needing assistance with hygiene. R24 described a pattern of staff turning off the call light without providing the needed help, causing frustration and distress. R24 was cognitively intact and able to accurately report the time they waited. The facility did not have call light logs available for R24, indicating a lack of documentation on response times. Resident R9's call light was activated for 30 minutes while a CNA was observed using their cell phone at the nurse's station. R9 required assistance with a mechanical lift to get out of bed and had informed staff of their need two hours prior. CNA E turned off R9's call light without providing assistance, stating they informed the assigned aide. The facility's policy requires all staff to respond to call lights, but this was not adhered to, resulting in prolonged wait times for residents.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of four residents, as observed during a survey. Resident 9 expressed dissatisfaction with the lack of activities, stating that there was nothing to do except ride in circles in their wheelchair. Resident 19 was observed wandering around the facility, expressing boredom and a desire to bird watch, but no activities were provided. Resident 20 reported that they used to be offered activities but had not been engaged in any for the past few months, relying on their family for leisure materials. Resident 32 mentioned the absence of an activities director and a lack of weekend activities, expressing a desire for off-site trips. The Activities Aide, working alone Monday through Friday, confirmed the lack of weekend coverage and the challenges in providing a comprehensive activities program. The facility's policy states that activities should support residents' choices based on their assessments, care plans, and preferences, aiming to enhance their physical, mental, and psychosocial well-being. However, the facility's current staffing and scheduling limitations have resulted in a failure to meet these standards, as evidenced by the lack of activity notes for the residents in question.
Deficiencies in Equipment Maintenance and Resident Safety
Penalty
Summary
The facility failed to ensure that essential patient equipment was in safe operating condition, leading to potential hazards and discomfort for several residents. One resident was observed with blood seeping from a bandage on her arm, which was attributed to cracked and worn wheelchair armrests that exposed sharp plastic edges. Despite the resident's complaints to staff about the discomfort and injury caused by the wheelchair, the issue was not addressed until it was brought to the attention of the surveyor. Another resident experienced multiple issues with their power wheelchair and the facility's mechanical lift. The resident reported discomfort and improper seating due to an ill-fitting air cushion, which caused them to slide out of the wheelchair frequently. The mechanical lift used for transfers was described as unstable and worn, with chipped paint and a loose anchor post, raising concerns about its safety. Despite these issues being known to staff, including the unit manager and CNAs, no corrective actions were taken to address the equipment's condition. Additional deficiencies were noted in the facility's maintenance of resident rooms and equipment. One resident's dresser was in disrepair, with missing and collapsed drawers, which had been reported to maintenance staff months prior without resolution. Another resident faced issues with their room's shower pressure and was told to purchase their own clock batteries, as the facility did not provide them. These maintenance oversights contributed to an environment where residents' needs and safety were not adequately prioritized.
Failure to Provide Mechanical Lift for Residents
Penalty
Summary
The facility failed to ensure the availability of a total assistance mechanical lift for two residents, resulting in their inability to safely get in and out of bed as desired. Resident R2, who has muscular dystrophy and anxiety disorder, was unable to get out of bed for four consecutive days in June 2024 due to the facility's lift being out for repairs. The fire department was called to assist R2 back into bed when the lift was unavailable. Interviews with staff, including the Maintenance Supervisor and the Director of Nursing, revealed a lack of documentation and awareness regarding the lift's repair status and duration of unavailability. Resident R9, who has cerebral infarction, hypoxia, and morbid obesity, also experienced issues due to the lack of a functioning mechanical lift. R9 reported that approximately two weeks prior, the facility did not have a working lift, which prevented them from attending a family event. Staff attempted to manually lift R9, which was deemed dangerous by the resident. The facility's policy on providing a safe and homelike environment was not adhered to, as the residents could not receive care and services safely due to the lift's unavailability.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner to the State Agency (SA) for one resident involved in an incident. The incident involved a resident, R45, who was observed by staff attempting to touch another resident, R4, inappropriately on the chest. This incident occurred on June 11, 2024, but was not reported to the SA until June 25, 2024, which is 14 days after the incident took place. The Director of Nursing (DON) acknowledged during a phone interview that all abuse investigations should be reported to the Abuse Coordinator and the SA promptly. However, the incident was delayed in reporting because the administrator was on vacation, and the DON was unsure of the reporting process in their absence. The facility's policy mandates that such incidents should be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. The failure to adhere to this policy resulted in the delayed reporting of the incident.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide the required written transfer notification to a resident and the Ombudsman when the resident was transferred to an acute care hospital. The deficiency was identified during an interview and record review, where the resident confirmed they were recently hospitalized due to a worsening bruise that developed into a wound. A review of the resident's census indicated hospitalization and subsequent return to the facility. However, the Electronic Medical Record (EMR) lacked documentation of the written transfer notification. Upon request, the facility's corporate administrative staff could not provide the written transfer notification or the Ombudsman monthly notification list by the time of the survey exit.
Failure to Implement Respiratory Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident requiring respiratory care. The resident, identified as R15, was observed on multiple occasions with an oxygen concentrator running, but the nasal cannula was found lying on the floor instead of being used by the resident. Despite the resident reporting difficulty breathing, there was no active physician's order for oxygen, and no care plan for oxygen or respiratory care was documented in the resident's medical record. R15 was admitted with diagnoses including Acute Respiratory Failure, Pneumonia, Adjustment Disorder with Anxiety, and Chronic Obstructive Pulmonary Disease. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition. During an interview, the MDS/Registered Nurse acknowledged that all orders should be transcribed and care plans written for each resident, but this was not done for R15. The facility's policy requires a baseline care plan to be developed and implemented for each resident, which was not adhered to in this case.
Failure to Update Fall Care Plan Interventions
Penalty
Summary
The facility failed to update the fall care plan interventions for a resident following multiple falls. The resident, who was observed with bruising on their forehead, reported a recent fall. A review of the resident's incidents and accidents from April to July revealed multiple falls, yet no new interventions were added to the care plan after these incidents. The last intervention on the care plan was dated in April, despite the resident experiencing several falls thereafter. The resident, admitted with diagnoses including encephalopathy and type 2 diabetes, had moderately impaired cognition and required supervision for all activities of daily living. Interviews with the MDS/RN and the DON confirmed that the care plan had not been updated with new interventions following each fall, contrary to the facility's policy. The policy requires the care plan to be reviewed and revised as necessary when a resident experiences a status change, with the interdisciplinary team collaborating on intervention options.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide consistent and scheduled showers for a resident who required assistance with activities of daily living (ADL), specifically bathing care. The resident expressed a desire to receive regular showers, stating that they were not being provided as scheduled, which was twice a week. The resident reported feeling upset and frustrated due to the lack of showers, as personal cleanliness was important to them. A review of the resident's ADL bath logs indicated that they received only four baths in a one-month period, with six instances where the activity did not occur, and no explanation was provided. Additionally, there was no documentation of any showers during the 30-day period, and the baths that were provided did not align with the resident's preference for evening or night showers. The resident's medical history included limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring maximal assistance with toileting and bathing/showers. The Director of Nursing acknowledged the resident's concerns and mentioned the difficulty in accommodating the resident's preferred shower time. The facility's policy on Activities of Daily Living, implemented in November 2022, stated that care and services should be provided based on the resident's comprehensive assessment and consistent with their needs and choices. However, the facility did not adhere to this policy, resulting in the resident's dissatisfaction with their bathing care.
Failure to Schedule Follow-Up Appointments and Ensure Oxygen Orders
Penalty
Summary
The facility failed to set up follow-up appointments for a resident, resulting in a delay of care. The resident, who had a fracture in their left knee and a left hip replacement, was observed with a swollen knee and a surgical dressing on the hip that had not been changed since the previous month. The resident reported missing four chemotherapy treatments since admission. The medical record indicated the need for follow-up with orthopedic and oncology physicians, but no appointments were scheduled until much later. The receptionist, responsible for scheduling, was unaware of the need for these appointments until recently, and the Director of Nursing was not familiar with the resident's situation. Additionally, the facility failed to ensure appropriate physician orders were in place for oxygen for another resident. This resident, with a history of acute respiratory failure, pneumonia, and COPD, was observed with an oxygen concentrator running but the nasal cannula on the floor. The resident reported difficulty breathing, and upon checking, there were no active physician orders for oxygen. The facility's policy required oxygen to be administered under physician orders, except in emergencies, but this was not followed. The MDS/RN indicated that all orders should be transcribed and care plans written, but this was not done for the resident's oxygen needs.
Failure to Provide Restorative Services for Resident with Limited ROM
Penalty
Summary
The facility failed to provide restorative services to a resident with limited range of motion and mobility needs. The resident, who was observed in a power wheelchair with a bent right arm and a tightly closed right hand, expressed a desire for exercise and range of motion therapy to maintain and improve mobility. Despite having physician orders for restorative therapy to maintain upper extremity strength and range of motion, the resident reported not receiving any restorative therapy or being enrolled in a therapy program. The resident's care plan indicated they were on a restorative program with specific exercises outlined, but there was no documentation in the electronic medical record of participation in a restorative exercise program. The resident's Minimum Data Set assessment revealed a history of limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring varying levels of assistance with daily activities. The resident was cognitively intact and experienced occasional pain. During an interview, the Director of Nursing was unaware of the resident not receiving restorative services and stated that the issue would be addressed. The facility's policy on Activities of Daily Living emphasized the provision of maintenance and restorative programs to assist residents in achieving the highest practicable outcomes, which was not adhered to in this case.
Failure to Ensure Timely Physician Response to MRR Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. The medical record review revealed pharmacy progress notes indicating irregularities on specific dates, but the complete MRR and pharmacy recommendations with physician follow-up were not available. An email request for these documents was made, but the facility was unable to provide them. The Director of Nursing (DON) indicated that the MRRs might be in a binder in the office, but they were not sure why they were not provided. Additionally, a policy for MRRs was requested but not received before the survey concluded.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. Resident 21, who was admitted with diagnoses of anxiety and rheumatoid arthritis, had physician orders for Alprazolam without a stop date. Despite having intact cognition, as indicated by a Brief Interview for Mental Status score of 15/15, the orders lacked the necessary stop date. Interviews with the Social Service Director and the Director of Nursing revealed that there was an expectation for all PRN anti-anxiety medications to have a 14-day stop date unless otherwise noted, but this was not implemented. Resident 44, who was nonverbal and had severely impaired cognition due to conditions such as encephalopathy, depression, and vascular dementia, also had a PRN order for Xanax without a stop date. The facility's policy on the use of psychotropic medications, which requires a 14-day limit on PRN orders unless justified by a physician, was not followed. Interviews with the Social Service Director and other staff indicated a lack of adherence to this policy, as there was no documentation justifying the continued use of the medication beyond the 14-day period.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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