Life Care Center Of Plainwell
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainwell, Michigan.
- Location
- 320 Brigham St, Plainwell, Michigan 49080
- CMS Provider Number
- 235471
- Inspections on file
- 28
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Life Care Center Of Plainwell during CMS and state inspections, most recent first.
Multiple residents with significant care needs experienced extended call light wait times, negative staff comments, and lack of respectful interactions, leading to unmet care needs and emotional distress. Staff and resident council interviews confirmed widespread delays, particularly during night shifts, and the facility had not provided recent staff education on dignity and respect.
A resident with a history of aggressive behavior, including schizophrenia and autism, physically assaulted another cognitively intact resident using a wheelchair. Despite multiple prior incidents of aggression, the facility did not implement new interventions or increase supervision, and staff were not present to prevent the assault. Required 15-minute checks were not consistently documented, contributing to the failure to protect residents from abuse.
A CNA who had not completed required dementia care and other annual trainings responded inappropriately to a resident with dementia by covering the resident's mouth with a gown and spraying aroma therapy mist in the resident's face, escalating the resident's distress. Facility leadership confirmed that staff training completion was not monitored, and the CNA had not attended in-person dementia care training beyond orientation, resulting in the potential for inadequate care.
A resident with severe dementia did not receive individualized care as required, when a CNA, lacking dementia care training, used unauthorized aroma therapy mist and covered the resident's mouth with a gown during an episode of agitation. This non-care planned intervention caused increased distress for the resident, and was not approved by nursing or medical staff.
A resident reported a missing wedding ring, but the facility failed to thoroughly investigate and resolve the grievance. The cognitively intact resident reported the loss to the Social Services Director, who documented the concern. The investigation, led by the Central Supply Director, did not find the ring, and the grievance process was incomplete as the Executive Director did not ensure follow-up. This resulted in the resident's grievance remaining unresolved.
The facility failed to maintain food safety and sanitation standards, with issues including improper cooling of beef roasts, expired sanitizing test strips, and cleanliness problems in the kitchen. The dish machine was also found to be operating below the required temperature, and the physical facilities showed signs of neglect.
A long-term care facility was found deficient in its infection control program, with staff failing to perform proper hand hygiene and glove changes during resident care, leading to potential cross-contamination. Equipment cleaning was inadequate, as tube feeding pumps and poles were visibly soiled. Enhanced Barrier Precautions were not consistently implemented, with staff failing to wear required protective gear and maintain sterile environments during wound care.
A facility failed to accurately document a resident's advance directives, leading to inconsistencies in their code status. Despite the resident's medical record indicating no advance directives, an order summary and care plan showed a DNR status. However, a physical chart incorrectly displayed 'Full Code'. Staff interviews revealed a lack of proper documentation and validation processes for code status changes.
The facility failed to provide bed-hold notifications to two residents who were transferred to the hospital, as required by policy. One resident, with diagnoses including surgical aftercare and shoulder pain, was hospitalized without receiving a bed-hold form. Another resident, with conditions such as Parkinson's and schizophrenia, was transferred to the hospital six times without receiving the necessary notification. Staff confirmed the absence of these forms in the residents' medical records.
A resident with a stage 3 pressure ulcer and cognitive intactness had an outdated care plan that included an indwelling catheter, despite its discontinuation. Observations and interviews confirmed the resident was incontinent and without a catheter, highlighting the facility's failure to update the care plan to reflect current needs.
A resident with hemiplegia following a stroke did not consistently receive restorative exercises as recommended, receiving them only 6 times out of 24 opportunities. This was due to the Restorative Aide's absence and reassignment to CNA duties, with no coverage for her restorative responsibilities. The facility identified the inconsistency during an audit, but corrective actions were not yet fully implemented.
A resident with an indwelling Foley catheter experienced leakage, resulting in saturated briefs and bedding with dark red urine. Despite staff awareness, the catheter was not changed, and the Director of Nursing was unaware of the issue. The facility's catheter care procedures, which include monitoring for complications and replacing the catheter when leakage occurs, were not followed.
A resident with PTSD and severe cognitive impairment did not have a care plan addressing PTSD triggers, leading to potential re-traumatization when another resident verbally threatened them. Staff were unaware of the resident's PTSD triggers, and no trauma-informed care assessment was conducted after the PTSD diagnosis.
A facility failed to protect residents from abuse, as one resident with severe cognitive impairment physically restrained another resident, causing emotional distress. Despite a policy against abuse, the facility did not manage the aggressive behavior, leading to a deficiency.
A facility failed to protect residents from verbal abuse by staff, involving three residents who reported incidents of intimidation and neglect by CNAs during night shifts. One resident, who was cognitively intact, was left on a bedpan all night and verbally intimidated. Another resident, who was cognitively impaired, experienced rude behavior and neglect in incontinence care. A third resident reported feeling uncomfortable due to dismissive and intimidating behavior by CNAs. The facility's inadequate response and lack of timely action contributed to the deficiency.
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, leading to potential continued mistreatment. A cognitively intact resident reported being left on a bedpan all night by a CNA who made inappropriate comments. Another resident, who was cognitively impaired, reported rude and unresponsive behavior from night shift CNAs. A third resident expressed dread about the night shift due to dismissive comments from a CNA. Despite these complaints, the facility did not conduct thorough investigations or report the concerns to the State Agency.
A facility failed to investigate and protect residents after abuse allegations involving three residents. A cognitively intact resident reported rough treatment and neglect by a CNA, while a cognitively impaired resident experienced rudeness and neglect. Another resident reported intimidation and annoyance from CNAs. The facility did not suspend the CNA immediately, delayed the investigation, and failed to report to the State Agency, resulting in an incomplete investigation and potential for future mistreatment.
A resident at moderate risk for pressure ulcers developed a Stage 2 ulcer and a deep tissue injury due to the facility's failure to implement necessary care plan interventions. Despite being cognitively intact and having limited mobility and incontinence, the resident's care plan lacked interventions for skin integrity and pressure ulcer prevention. The resident was reportedly left on a bedpan overnight, contributing to skin damage, and the care plan was not updated to reflect these conditions.
Two residents in a LTC facility developed moisture-associated skin disorder (MASD) due to inadequate incontinence care. One resident, immobile and at moderate risk for pressure wounds, lacked a care plan for skin integrity, resulting in MASD and a pressure ulcer. Another resident reported a painful open area on her buttocks after her incontinence brief was not changed all day, with staff unaware of her MASD concerns. Interviews revealed a lack of awareness and response to residents' incontinence care needs, highlighting systemic failures in care provision.
A facility failed to monitor the weight of a newly admitted resident at risk for malnutrition, resulting in a significant weight loss of 6.8% over three weeks. The resident's care plan required weekly weight monitoring, but this was not done due to unclear responsibilities among staff. The RD was aware of the risk but did not ensure weekly monitoring, and the LPN and DON confirmed that the necessary orders were not in place.
A resident with Parkinson's disease and dementia was not provided with the necessary assistive devices and positioning support as outlined in their care plan. Observations revealed the resident leaning in bed and in a Geri chair without proper alignment aids, leading to discomfort. The facility staff did not follow the care plan interventions or repositioning policies, resulting in a deficiency.
A resident with Parkinson's disease and dementia was observed multiple times without accessible fluids, leading to signs of dehydration such as dry and cracked lips. Despite the care plan requiring drinks in sip cups, staff failed to provide them, and the resident's over-the-bed table was consistently out of reach. The facility's policy to ensure fluid availability at all times was not followed.
A resident with Parkinson's disease and dementia did not receive prescribed assistive devices, such as sip cups and plate guards, during meals, leading to potential issues with oral intake. Observations showed the resident in positions that hindered effective eating and drinking, and staff interviews confirmed the lack of necessary devices. The water pass census required a sip cup, but a styrofoam cup was provided instead, which the resident could not use effectively.
A resident with Parkinson's disease and dementia required enhanced barrier precautions due to a foley catheter and g-tube. Despite clear signage and facility policy, staff failed to consistently wear gowns and gloves during personal care, as observed in multiple instances. Interviews with staff confirmed the expectation to use PPE, but adherence was lacking.
Failure to Promote Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by extended call light wait times, negative staff comments, and lack of appropriate staff education. One resident with critical illness myopathy and end stage renal disease reported frequent delays of 30-45 minutes for call light responses, overheard staff referring to him as 'cranky,' and felt staff were retaliating against him after voicing concerns. The resident expressed feelings of anger, frustration, and being dehumanized, and stated that previous complaints to management were not addressed, leading him to stop reporting issues. Another resident with hemiplegia following a stroke, who required assistance with bed mobility and personal hygiene, reported waiting at least 30 minutes for staff to answer her call light. She described experiencing pain while waiting to be repositioned and discomfort from remaining in a soiled brief for extended periods. This resident stated that the delays made her feel sad and angry. A third resident with anxiety and depression also reported long call light wait times, particularly at night and on weekends, sometimes waiting so long that her needs went unmet and she fell asleep without assistance. Staff interviews confirmed that residents had complained about long call light wait times, especially during the night shift. Resident council meeting minutes and a confidential group interview further corroborated that multiple residents experienced extended wait times, with reports of waiting over 45 minutes during evening hours across several facility halls. The facility's own dignity policy emphasized the importance of treating residents with respect and enhancing their self-worth, but the lack of recent staff education and the ongoing issues with staff-resident interactions contributed to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from physical abuse, resulting in one resident physically assaulting another. The incident involved a male resident with schizophrenia and autism, who had a documented history of aggressive behaviors, including hitting, biting, and throwing objects at both staff and other residents. Despite multiple documented episodes of aggression in the weeks leading up to the incident, no new interventions or increased supervision were implemented to address the escalating behaviors. On the day of the incident, the aggressive resident exited his room and struck another male resident, who was cognitively intact and using a wheelchair, in the face. Staff interviews confirmed that there was no staff present in the hallway or at the nurses' station at the time of the assault, and that the aggressive resident was able to approach and hit the other resident without intervention. The assaulted resident sustained redness to his cheek, and the aggressor incurred a minor laceration from contact with the wheelchair. Prior to the assault, the aggressive resident had also thrown a drink at another resident, but the facility did not increase supervision or implement additional safety measures following this event. The care plan for the aggressive resident noted his history of physical aggression but was not updated with new interventions after repeated incidents. Documentation also revealed that required 15-minute checks, which were eventually added to the care plan, were not consistently performed or documented.
Plan Of Correction
Resident #102 still resides in the facility. The resident has not had any further encounters with other residents and continues to show no signs of distress from the 5/12/25 and 6/17/25 incidents. Resident #101 still resides in the facility and has not had any further issues of aggression with other residents. Facility residents have the potential to be affected by the alleged deficient practice. The Social Services Director/designee completed facility-wide interviews with residents to ensure there were not any unaddressed concerns on 7/1-7/3/25. Any discrepancies noted with the interviews were addressed at that time. The Staff Development Coordinator/Designee will provide re-education to all staff on the facility abuse prevention policy and de-escalation tips for challenging behaviors on or before 7/14/25. Staff will not be allowed to work until education is completed. The IDT will review 24-hour reports for resident-to-resident encounters for potential abuse. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. The Social Service Director/Designee will audit resident concerns to review for potential abuse allegations during IDT meetings. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Executive Director is responsible for ongoing compliance.
Failure to Ensure Nursing Staff Competency and Completion of Required Dementia Training
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a Certified Nursing Assistant (CNA), had the appropriate skill sets and completed required annual trainings, as mandated by facility policy and federal regulations. The facility's policy required all staff to receive training on dementia care upon hire, annually, and as needed, with the Staff Development Coordinator responsible for maintaining training records. However, review of training records revealed that one CNA had not completed 60 out of 62 required trainings over a 13-month period, including essential topics such as dementia care, challenging behaviors, and mental health in LTC. The facility assessment indicated that dementia and cognitive impairment were prevalent among residents, with 19 residents diagnosed with dementia in the previous two quarters, and all staff were expected to be trained in these areas. An incident occurred in which a resident with dementia began yelling in the hallway. The CNA in question, who had not completed the required dementia care training, responded by pulling the resident's gown up to cover his mouth and then spraying an aroma therapy mist toward the resident's face, which also affected another CNA present. This action caused the resident to become more agitated. The CNA later admitted to being stressed by the resident's behaviors and confirmed she did not recall receiving any dementia care training from the facility. The other CNA present reported that the actions taken by the untrained CNA escalated the resident's distress. Interviews with facility leadership, including the Staff Development Coordinator, Human Resources Director, and Nursing Home Administrator, confirmed that staff completion of required trainings had not been monitored until recently. Staff were only able to complete computer-based trainings while in the facility, and there were reported difficulties accessing available computers. The facility had no documentation of the CNA attending any in-person dementia care training during her employment, aside from initial orientation. This lack of training and oversight resulted in the potential for delivery of care that did not support the resident's highest practicable well-being.
Plan Of Correction
Resident #103 no longer resides at the facility. CNA S no longer works at the facility. Facility residents have the potential to be affected. The DON/Designee conducted an audit to identify CNAs who have not completed Dementia training on 7/2/25. The Staff Development Coordinator/Designee will educate licensed nurses and certified nursing aides on education and training requirements and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. CNA s will be required to have completed at least 2 dementia-related training courses within the past 12 months prior to 7/14/25. The DON/Designee will conduct weekly audits of CNA education assignments to ensure that education is being completed. The audit will be conducted one time per week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.
Failure to Provide Individualized Dementia Care and Unauthorized Use of Aroma Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia did not receive individualized care interventions as outlined in their care plan. The resident, who had a BIMS score indicating severe cognitive impairment and a history of dementia and cognitive communication deficit, was subjected to actions by a CNA that were not authorized or tailored to their needs. The care plan specified approaches such as allowing extra time for responses, using simple instructions, and providing cues, but these were not followed during the incident. On the night in question, the resident became agitated and began yelling in the hallway. A CNA responded by pulling the resident's gown up over their mouth and spraying an aroma therapy mist directly at the resident's face, actions which were not part of the resident's care plan and had no physician order. This intervention caused the resident to become further agitated, resulting in physical resistance and distress. Other staff members witnessed the incident and reported that the resident only calmed down after alternative, individualized calming strategies were used. Interviews with staff revealed that the CNA had not received required dementia care training and had independently brought the aroma therapy spray into the facility without authorization from nursing or medical staff. Multiple staff members confirmed that the use of aroma therapy mist was not approved or ordered for any residents, and the facility's policy required individualized, person-centered interventions for dementia care. The facility also had not been monitoring staff compliance with required dementia care training at the time of the incident.
Plan Of Correction
Resident #103 no longer resides in the facility. Facility residents with a diagnosis of dementia have the potential to be affected. The DON/Designee conducted an audit to identify those residents who have been diagnosed with dementia and were reviewed by the Interdisciplinary Team for appropriate interventions. Their personalized care plans will be reviewed for accuracy on or by 7/11/25. The SDC/Designee will educate nurses and CNAs on the Caring for Dementia policy, creating and following individualized care plan interventions, 10-Tips to De-Escalate Challenging Situations, and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. The DON/designee will complete audits three times a week for eight weeks or until substantial compliance is achieved of newly admitted and readmitted residents with a dementia diagnosis to ensure their care plan includes individualized interventions. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.
Failure to Resolve Resident's Grievance on Missing Item
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for a resident who reported a missing wedding ring. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported the loss of his wedding ring several months ago. The concern was documented by the Social Services Director, who noted that the resident had reported the missing item to her. The investigation was assigned to the Central Supply Director, who conducted a search in the resident's room but did not find the ring. However, the investigation was incomplete as the actions taken to resolve the concern, the date and time of findings, and the executive director's signature were left blank on the concern form. Interviews with the Social Services Director and the Executive Director revealed that the facility's grievance process was not followed through to completion. The Social Services Director stated that the concern forms are initially handled by her and then passed to the appropriate department head, who is responsible for resolving the issue before it is reviewed and signed off by the Executive Director. However, in this case, the completed concern form was not returned to the Social Services Director, and the Executive Director acknowledged that there was no follow-up completed on the missing ring. This lack of follow-through resulted in the resident's grievance remaining unresolved.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a kitchen tour. A full pan containing two beef roasts was found in the walk-in cooler with a vented top, and the Food Service Director (FSD) was unable to provide a cooling log for the item, stating it was erased during cleaning. The roast was cooked the previous day and placed in the cooler at a temperature between 160F and 170F, but the FSD was unaware of the required time and temperature for proper cooling. The roast was eventually discarded due to uncertainty about its cooling process. Additional issues were noted with expired quaternary ammonium test strips, which are necessary for measuring sanitizing solution concentrations. The FSD acknowledged that both the current and backup test strips were expired. Furthermore, the kitchen was found to have cleanliness issues, including crumb debris in utensil drawers, debris on muffin tins, and black debris on can openers. A bus tub with kitchen equipment contained a dead moth and sticky debris, indicating a lack of regular cleaning and maintenance. The dish machine area also presented problems, with the machine running below the required 160F for the wash cycle, as indicated by the manufacturer's data plate. The dish log showed that 19 out of 24 logged wash temperatures were below the required minimum. Additionally, the physical facilities, such as the floor juncture under the dish machine and the dry storage room, were found to have accumulations of dirt and grime, further highlighting the facility's failure to maintain a clean and safe food service environment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies in hand hygiene and glove use during resident care. In one instance, a cognitively intact resident with a pressure ulcer and catheter care orders was observed receiving care from a hospice RN and CNAs who repeatedly failed to perform hand hygiene between glove changes. The RN handled soiled briefs and bed linens, touched the resident's urinary catheter, and managed wound care without proper hand hygiene, increasing the risk of cross-contamination and infection. Additionally, the facility did not ensure the proper cleaning and disinfecting of resident equipment. Observations revealed that tube feeding pumps, poles, and bases for two residents were splattered with dried formula and debris, indicating a lack of routine cleaning. Housekeeping staff confirmed that these items were part of a monthly deep clean list, but the visible dirt and debris suggested that cleaning protocols were not being followed consistently. The facility also failed to implement Enhanced Barrier Precautions (EBP) as required. A resident with a stage 3 pressure ulcer and a history of multidrug-resistant organisms was observed receiving care without the CNA wearing a gown, despite signage indicating the need for such precautions. Furthermore, during wound care, an LPN placed soiled dressing supplies into a clean field and failed to perform hand hygiene before applying gloves, compromising the sterile environment necessary for wound care. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of advance directives for a resident with multiple sclerosis, who was cognitively intact. The resident's medical record contained a document indicating no advance directives were chosen at the time, yet an order summary and care plan indicated a DNR status with comfort measures was active. However, a physical chart at the nurse's station incorrectly displayed a 'Full Code' status. Interviews with nursing staff revealed inconsistencies in the process of updating and validating code status changes, with a lack of proper documentation and signatures from witnesses and the physician. Further investigation showed that during a hospital readmission, a conversation about the resident's code status change was reportedly held, but no documentation was found to support this. The Social Services Director indicated that the nursing department handles advance directives, but no documentation was found in the resident's medical record to confirm the resident's DNR wishes. The facility's policy requires review and documentation of advance directives upon admission, quarterly, and when there is a change in the resident's condition, but this was not adhered to in this case.
Failure to Provide Bed-Hold Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed-hold notifications to residents who were transferred to the hospital, as required by their policy. This deficiency was identified for two residents, Resident #41 and Resident #2, who were hospitalized without receiving the necessary bed-hold forms. Resident #41, who was readmitted to the facility with diagnoses including surgical aftercare and shoulder pain, was sent to the emergency room due to a leaking abscess and deep vein thrombosis. However, there was no evidence in the medical record that a bed-hold notice was provided for this hospitalization. The Director of Nursing confirmed that the facility was unable to locate the form for Resident #41's hospitalization. Similarly, Resident #2, who was cognitively intact and had diagnoses including Parkinson's, seizures, bipolar disorder, and schizophrenia, was transferred to the hospital six times in 2024 without receiving a bed-hold form. During interviews, both the Director of Nursing and the Unit Manager acknowledged that bed-hold notifications should be provided with each hospital transfer. However, the forms were not found in the resident's medical records or the facility's filing system. Medical Records staff also confirmed that no bed-hold forms were uploaded into the electronic medical records for Resident #2.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident, resulting in an inaccurate reflection of the resident's current care needs. The resident, who was cognitively intact with a BIMS score of 15/15, had a diagnosis of a stage 3 pressure ulcer in the sacral region. Initially, the care plan included an intervention for an indwelling catheter, which was initiated on 9/4/2024. However, observations and interviews revealed discrepancies in the care plan. On 10/8/2024, the resident was observed without a urine drainage bag, and subsequent notes indicated that the wound vac and foley catheter had been discontinued by 9/20/2024. Further observations and interviews confirmed that the resident was incontinent of bowel and bladder and did not have a foley catheter at the time of the survey. Despite these changes, the care plan still included an intervention for an indwelling catheter, which was no longer applicable. The Licensed Practical Nurse Unit Manager confirmed that the care plan should have been updated to reflect the resident's current condition, indicating a failure in maintaining an accurate and up-to-date care plan for the resident.
Inconsistent Restorative Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to consistently provide restorative exercises as recommended for a resident with hemiplegia and hemiparesis following a stroke, resulting in the potential for pain, stiffness, and avoidable decline. The resident, who was cognitively intact, reported receiving therapy initially but was now dependent on restorative exercises due to insurance limitations. The restorative program was developed by therapy and was supposed to be administered by a Restorative Aide and overseen by a Restorative Program Nurse. However, the resident received restorative exercises only 6 times out of 24 opportunities over an 8-week period. This inconsistency was attributed to the Restorative Aide having days off and being reassigned to work as a CNA, with no coverage for her restorative duties. The Restorative Program Nurse confirmed the inconsistency and acknowledged that the facility had identified the issue during an audit, but a plan to address it was not yet fully implemented.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, resulting in the potential for urinary tract injury and/or infection. The resident, who was cognitively intact and dependent on staff for activities of daily living due to obstructive uropathy, had an indwelling catheter that was observed to be leaking. During observations, the resident's brief and bedding were found saturated with urine, and the urine collection bag contained dark red urine. Certified Nursing Assistants reported that the catheter had been leaking for some time and had not been changed, despite the knowledge of the nursing staff. The Director of Nursing was unaware of the catheter leakage issue, and the Unit Manager mentioned discussions about removing the catheter to allow the resident to urinate naturally, but no action had been taken. A previous progress note indicated that the catheter had been changed due to leaking several months prior. The facility's procedure for catheter care emphasized monitoring for complications, maintaining a sterile closed system, and replacing the catheter when leakage occurs, but these protocols were not followed, leading to the deficiency.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address Post Traumatic Stress Disorder (PTSD) triggers for a resident, leading to a lack of trauma-informed care. The resident, who had a diagnosis of PTSD, dementia with psychotic disturbance, adjustment disorder, and obsessive-compulsive disorder, did not have a care plan that included focus, goals, or interventions related to PTSD or any possible triggers. Despite the resident's severe cognitive impairment and history of abuse, there was no trauma-informed care assessment conducted after the PTSD diagnosis, and staff members, including LPNs and the Social Services Director, were unaware of the resident's triggers. An incident occurred where another resident verbally threatened the resident with PTSD, which could have been re-traumatizing. The threatening behavior was reported, but repeated attempts to contact the witness were unsuccessful. Observations of the resident showed signs of distress, such as yelling out monosyllable noises, but staff interviews revealed a lack of awareness and documentation regarding the resident's PTSD and potential triggers. The Social Services Director confirmed that trauma assessments should be completed at admission and with new diagnoses, but this was not done for the resident in question.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, as evidenced by incidents involving two residents. Resident #80, who was severely cognitively impaired, exhibited aggressive behavior towards her roommate, Resident #61. On one occasion, Resident #80 pulled her roommate from her wheelchair and restrained her on the floor, causing physical and emotional distress. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that Resident #80 was confused and believed Resident #61 was trying to leave the room for inappropriate reasons. Resident #61, who was moderately cognitively impaired and used a wheelchair for mobility, experienced fear and emotional distress following the altercation with Resident #80. The incident report and interviews indicated that Resident #61 was unable to comment on the event due to her cognitive communication deficit but expressed feelings of being stuck at the facility. The CNA described Resident #61 as being in shock and fearful after the incident, highlighting the emotional impact of the physical restraint. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse, including physical restraint by other residents. Despite this policy, the facility did not adequately prevent or address the aggressive behavior of Resident #80, resulting in a failure to protect Resident #61 from abuse. The report indicates that the facility's inaction in managing Resident #80's behavior and ensuring the safety of Resident #61 contributed to the deficiency.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse by staff, specifically involving three residents. Resident #102, who was cognitively intact, reported being verbally intimidated by a CNA who told her not to wet the bed while placing her on a bedpan. The resident's daughter corroborated this account, stating that the resident had been left on the bedpan all night. The resident had a history of stroke and was incontinent, which made her dependent on staff for toileting assistance. The facility's care plan for Resident #102 lacked specific interventions for toileting and skin integrity, which may have contributed to the incident. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unhelpful. He recounted an incident where a CNA refused to change his brief after multiple bowel movements, telling him he would have to wait for the next shift. This resident also reported that another CNA was stern and restrictive about his choice of sleepwear. The facility's documentation showed that a concern form was completed but not promptly addressed, and the CNA involved was eventually terminated. Resident #105, who was cognitively intact, expressed dread about the night shift due to the CNAs' behavior. She reported that a CNA was dismissive and intimidating, making her feel uncomfortable when requesting incontinence care. The facility's response to these complaints was inadequate, as there was no evidence of follow-up interviews with other residents or staff, and the concerns were not reported to the State Agency. The lack of timely and appropriate action by the facility's administration contributed to the deficiency in protecting residents from abuse.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for continued violations involving mistreatment, neglect, or abuse going undetected, unreported, or without thorough investigation. Resident #102, who was cognitively intact, reported that a CNA had left her on a bedpan all night and made inappropriate comments. This incident was documented by RN D after being informed by the resident's daughter and the resident herself. However, the report was not immediately escalated to the State Agency. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unresponsive to his needs. He specifically mentioned an incident where a CNA refused to change his brief after multiple requests. This concern was documented by the Director of Rehabilitation but was not interpreted as an allegation of abuse or neglect by the DON, and thus, was not reported to the State Agency. Resident #105, who was cognitively intact, expressed dread about the night shift due to the behavior of the CNAs, particularly CNA G, who made dismissive comments. Despite multiple complaints from residents about CNA G, the Nursing Home Administrator did not conduct further interviews with other residents or staff, nor did they report the concerns to the State Agency. The lack of timely reporting and thorough investigation of these allegations constitutes a deficiency in the facility's handling of potential abuse cases.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to adequately investigate and protect residents following allegations of abuse involving three residents. Resident #102, who was cognitively intact, reported that a CNA had been rough, yelled at her, and left her on a bedpan all night. Despite the report being made, the CNA was not immediately suspended, and the investigation was incomplete. The facility's response was delayed, and the incident was not reported to the State Agency. Resident #103, who was cognitively impaired, reported that a CNA was rude and refused to change his brief during the night, telling him he would have to wait for the next shift. A complaint form was filled out, but the investigation and response were incomplete. The Director of Nursing (DON) did not interpret the complaint as an allegation of abuse or neglect and did not report it to the State Agency. The CNA was eventually terminated, but the process was delayed, and the investigation was not thorough. Resident #105, who was cognitively intact, reported that the night shift CNAs were not nice, with one CNA being intimidating and another acting annoyed when asked for assistance. The facility did not follow up with the residents or report the concerns to the State Agency. The Nursing Home Administrator admitted to not interviewing other residents or staff and not reporting the concerns, resulting in an incomplete investigation and potential for future mistreatment.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent the development of pressure ulcers for a resident, resulting in a Stage 2 pressure ulcer on the right buttock and a deep tissue injury on the coccyx. The resident, who was admitted with a history of stroke and was cognitively intact, was identified as being at moderate risk for pressure ulcers due to limited mobility, incontinence, and other factors. Despite these risks, the resident's care plan did not include necessary interventions for skin integrity and pressure ulcer prevention. The resident developed moisture-associated skin damage (MASD) and subsequently a Stage 2 pressure ulcer, which were not addressed in the care plan or assessed by a physician before the resident's discharge. Interviews with facility staff revealed that the resident was left on a bedpan overnight, which may have contributed to the skin damage. The resident's family member reported that the resident was immobile and incontinent, and had been treated roughly by a CNA. The Director of Nursing was unable to provide additional information on why appropriate interventions were not in place. The lack of documentation and failure to update the care plan contributed to the development of the pressure ulcers.
Inadequate Incontinence Care Leads to Skin Disorders
Penalty
Summary
The facility failed to maintain professional standards of care and provide adequate incontinence care for two residents, resulting in moisture-associated skin disorder (MASD). Resident #102, who was cognitively intact but immobile due to a recent stroke, was admitted without a care plan addressing her incontinence and skin integrity needs. Despite being at moderate risk for pressure wounds, no interventions were in place, leading to the development of MASD and a Stage 2 pressure ulcer. Reports indicated that Resident #102 was left on a bedpan overnight, which may have exacerbated her condition. Resident #106, also cognitively intact, reported developing a painful open area on her buttocks due to her incontinence brief not being changed throughout the day. Despite having a care plan indicating a risk for skin breakdown, there were no person-centered interventions for her incontinence care needs. The resident's call light was reportedly ignored by CNAs, and her incontinence task record showed frequent incontinence episodes. A physician's order for MASD treatment was incomplete, lacking a medication name, and staff were unaware of the resident's MASD concerns until the surveyor's intervention. Interviews with facility staff revealed a lack of awareness and appropriate response to the residents' incontinence care needs. The LPN responsible for Resident #102's admission failed to develop a baseline care plan, and the Director of Nursing could not provide additional information on why interventions were not in place. For Resident #106, the LPN was unaware of the MASD issue and had to correct the treatment order after the surveyor's inquiry. These deficiencies highlight a systemic failure in providing adequate incontinence care and maintaining skin integrity for residents at risk.
Failure to Monitor Weight of Resident at Risk for Malnutrition
Penalty
Summary
The facility failed to ensure timely monitoring of weight for a newly admitted resident, Resident #105, who was at risk for malnutrition. According to the facility's policy, a resident's weight should be recorded at the time of admission, weekly for four weeks, and then monthly. However, Resident #105's weight was not monitored weekly as required. The resident was admitted with a diagnosis of malnutrition and adult failure to thrive, and the care plan included monitoring for significant weight loss. Despite this, there was no record of weights taken between the initial weight of 144.1 pounds on 6/9/24 and a subsequent weight of 134.3 pounds on 7/1/24, indicating a 6.8% weight loss in three weeks. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for ordering and monitoring weekly weights. The Registered Dietician (RD) was aware of the resident's risk for malnutrition but did not know if weights were monitored weekly. The Licensed Practical Nurse (LPN) stated that newly admitted residents are weighed weekly, but this was not done for Resident #105. The Director of Nursing (DON) confirmed that the nurse responsible for the resident's admission should ensure weight monitoring orders are in place, but this was not done for Resident #105, leading to a delay in identifying significant weight loss.
Failure to Implement Resident Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination. The resident was observed multiple times in positions that did not align with the care plan interventions, such as leaning to the right side in bed without assistive devices or pillows for proper body alignment. The resident's care plan included the use of a lateral wedge cushion and assistance with eating and drinking, but these measures were not observed during the surveyor's visits. Additionally, the resident was seen in a Geri chair in positions that were uncomfortable and lacked proper support, such as a hyper-extended neck and leaning to the left without adequate positioning aids. Despite the care plan's directives, the staff did not utilize assistive devices or reposition the resident to ensure comfort and alignment. Interviews with the Director of Nursing revealed that the staff did not adhere to the facility's policies and procedures for repositioning residents, which contributed to the deficiency.
Failure to Provide Accessible Hydration to Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as Resident #102, had access to fluids for hydration, resulting in the potential for dehydration. Resident #102 had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact with a BIMS score of 13/15. Observations on multiple occasions revealed that Resident #102's over-the-bed table, which held water and meal trays, was consistently placed out of reach, leading to dry and cracked lips, a sign of dehydration. During one observation, Resident #102 was found with a wet shoulder and an empty styrofoam cup, indicating an attempt to drink water that resulted in spillage. Interviews with staff revealed that the CNA responsible for water pass did not provide Resident #102 with the appropriate sip cup, despite the care plan indicating that all drinks should be in sip cups. The Director of Nursing stated that water should be passed to every resident at least twice a day and that residents should always have access to drinkable water. However, the facility's policy on hydration and nutrition, which mandates that fluid is available to residents at all times, was not adhered to, as evidenced by the repeated observations of Resident #102 without accessible fluids.
Failure to Provide Assistive Devices for Resident
Penalty
Summary
The facility failed to provide assistive devices as ordered for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination, which resulted in the potential for a decline in oral intake of food and fluids. The resident was cognitively intact and had specific physician orders for a regular diet with all drinks in sip cups and a plate guard. However, during multiple observations, the resident was found without the necessary assistive devices, such as sip cups and plate guards, during meals. The resident's care plan also indicated a risk for dehydration and required assistance with eating and drinking, which was not adequately provided. Observations revealed that the resident was often in positions that compromised her ability to eat and drink effectively, such as leaning to one side in bed or in a reclined Geri chair without proper support or positioning aids. Interviews with staff, including a registered dietician and certified nurse assistants, confirmed that the resident was not receiving the prescribed assistive devices. The water pass census indicated that the resident required a sip cup, but staff provided a styrofoam cup instead, which the resident could not use effectively. These failures in providing the necessary assistive devices and positioning support contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control enhanced barrier precautions for a resident, leading to the potential for the spread of infection. The resident had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact. The resident's care plan and physician orders required enhanced barrier precautions, including the use of gowns and gloves during personal care due to the presence of a foley catheter and g-tube. However, during observations, staff members were noted not adhering to these precautions. Specifically, a CNA was observed providing personal care without wearing the required personal protective equipment (PPE), and another CNA performed catheter care without donning a gown, despite the signage indicating the need for such precautions. Interviews with staff, including CNAs, an LPN, the RN/Infection Preventionist, and the Director of Nursing, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents requiring enhanced barrier precautions. The facility's policy on enhanced barrier precautions, reviewed on a specific date, also outlined the necessity of using gowns and gloves during high-contact care activities for residents with indwelling medical devices. Despite these guidelines, the staff did not consistently follow the required infection control measures, as evidenced by the observations and interviews.
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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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