Lynwood Manor Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Adrian, Michigan.
- Location
- 730 Kimole Lane, Adrian, Michigan 49221
- CMS Provider Number
- 235182
- Inspections on file
- 25
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lynwood Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including epilepsy, DM2, HTN, weakness, gait difficulty, and a prior sacral fracture, was being transported in a wheelchair van from an outside appointment. The facility driver anchored the wheelchair to the van floor but did not ensure that the van seat belt was applied to the resident. While driving, the driver encountered backed-up traffic around a blind corner and braked hard, causing the resident to be thrown from the wheelchair onto the van floor. The resident was subsequently transported to a hospital and later readmitted with new fractures of the distal femur, fibula, and bimalleolar ankle.
A resident suffered a second-degree burn from hot coffee served at unsafe temperatures, with facility records showing inconsistent temperature monitoring. Additionally, two residents lacked proper smoking assessments, increasing injury risks. The facility's policies did not adequately address these issues.
The facility failed to provide palatable food products to 66 residents, leading to potential nutritional decline. Observations showed food items were not kept at safe temperatures, with milk at 47.8°F and other items below 135°F. Residents expressed dissatisfaction with the food quality, describing it as mushy and overcooked. The facility's policies on food safety were not followed, contributing to the deficiency.
The facility failed to maintain cleanliness and proper maintenance in its food service operations, affecting 66 residents. Issues included a missing tile surface, a loose ice machine door, and a malfunctioning cooler door closer. Opened food containers lacked proper date marking, and equipment was found soiled with food residue, increasing the risk of foodborne illness.
The facility failed to ensure that two LPNs completed the required initial and annual competency evaluations. The personnel records for these LPNs lacked documentation of necessary evaluations, and the facility's policy on Competency Evaluation was found to be inadequate. The DON confirmed the deficiency, and the facility was unable to provide the required evaluations by the time of the survey exit.
The facility failed to maintain a clean and safe environment, affecting 66 residents. Observations included damaged drywall, non-functional ventilation, and slow-draining sinks. Interviews revealed a lack of documented work orders addressing these issues, despite existing policies for regular cleaning and maintenance.
A facility failed to provide timely financial statements to a resident's responsible person, resulting in a lack of information about the resident's personal funds. The resident, with severe cognitive impairment, had a financial account managed by the facility. The responsible person, holding the Durable Power of Attorney, reported not receiving any quarterly financial statements. The Business Office Manager admitted that the facility had not received or mailed out quarterly statements for an undetermined amount of time.
A resident with multiple sclerosis and malnutrition sustained a burn from spilled hot coffee. Initially treated as a second-degree burn, the burn's condition worsened, resembling a third-degree burn. The facility failed to notify the physician of this change, resulting in a deficiency.
A facility failed to provide a resident with necessary Medicare non-coverage notices after a change in payment source from Medicare to pending Medicaid. Despite being cognitively intact, the resident did not receive a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) before the end of Medicare Part A services. The social worker responsible for issuing these notices could not explain the oversight.
A facility failed to provide wound care per physician orders for a resident, leading to the likelihood of infection and delayed healing. The resident had saturated dressings on both arms, dated five days prior, despite orders for wound care every Monday, Wednesday, and Friday. Staff interviews revealed confusion and miscommunication about responsibility for changing the dressings, resulting in a deficiency.
A resident with a history of traumatic brain injury and stroke was not provided with restorative ambulation services, despite recommendations for staff assistance. The facility lacked a restorative nursing program, and staff interviews confirmed no ambulation assistance was given, leading to the resident's sadness and fear of losing mobility.
A resident with multiple sclerosis and severe malnutrition experienced significant weight loss due to the facility's failure to provide a prescribed therapeutic diet. Despite a physician's order for double protein portions, the resident's meal did not include the required portions, as confirmed by a registered dietitian.
A resident with sleep apnea and other health conditions was not using a CPAP machine due to a missing part. The facility had no physician orders for the CPAP and was unaware of its necessity until contacting the resident's power of attorney.
A facility failed to maintain a medication error rate below 5%, with errors involving two residents. An LPN left a MiraLAX solution unattended for a resident with dysphagia, and incorrectly administered crushed medications through a feeding tube for another resident, against facility policy. The Director of Nursing confirmed these actions were not compliant with established procedures.
A resident with dietary restrictions due to renal dialysis and diabetes was served meals containing allergens and intolerances, such as peppers and tomato products, despite clear instructions on her meal tray ticket. Additionally, the resident did not receive the appropriate breakfast on dialysis days, as the kitchen failed to provide the specified sack breakfast items, leaving her without food until late morning.
Failure to Secure Resident With Seat Belt During Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate accident-prevention interventions during transport for one cognitively intact resident. The resident was admitted with multiple diagnoses including left knee pain, diverticulosis, bone density disorder, epilepsy, hyperlipidemia, hypertension, type 2 diabetes, weakness, difficulty walking, lack of coordination, and a sacral fracture. The resident was later discharged from the facility following an incident that occurred while being transported back from an outside appointment. Upon readmission, the resident had new diagnoses of distal femur fracture, fibula fracture, and bimalleolar ankle fracture. According to the facility’s investigation and staff interview, the facility driver placed the resident in the facility van and anchored the wheelchair to the floor using the appropriate strap devices but did not ensure that the van seat belt was applied to the resident. While returning to the facility, the driver encountered backed-up traffic around a corner with a significant blind spot and had to brake hard. As a result, the resident came out of the wheelchair and landed on the van floor. The driver then pulled into a business parking lot, assessed the resident, contacted the facility, and was directed to call 911, after which the resident was transported to a hospital. The driver later stated he thought the seat belt had been applied but had apparently forgotten to do so.
Failure to Ensure Safe Coffee Temperatures and Smoking Assessments
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature, resulting in a second-degree burn for a resident. The resident, who had multiple sclerosis and severe protein-calorie malnutrition, reported that hot coffee spilled on his leg, causing a burn. The coffee was served with a lid that did not seal properly, leading to the spill. The facility's records did not document the coffee temperature at the time of the incident, and the coffee temperature logs showed temperatures exceeding the facility's policy. The facility's investigation into the incident did not include a root cause analysis or identify the staff member who provided the coffee. Interviews with staff revealed inconsistencies in the temperature monitoring process, with coffee temperatures often exceeding safe limits. The dietary manager acknowledged that the coffee machine brewed coffee at temperatures higher than the policy allowed, and there was no consistent monitoring of self-serve coffee stations. Additionally, the facility failed to perform safe smoking assessments for two residents, increasing the likelihood of injuries. One resident was observed with vaping devices, but their care plan did not address vaping. Another resident's smoking assessment did not mention vaping, and staff were unaware of the resident's vaping habits. The facility's smoking policy lacked guidance on vaping, and the residents were not included on the facility's list of smokers.
Removal Plan
- The NHA called an Ad Hoc QAPI meeting, which included the DON, Medical Director, Assistant Director of Nursing, MDS Coordinator, Registered Dietitian, and Dietary Manager. A root cause analysis was completed for the burn to Resident #28.
- Dietary Manager and Registered Dietitian educated dietary staff on proper temping and serving of hot beverages. Hot beverages must be temped and logged prior to and during meal service. The temperature of hot beverages must be taken prior to any request by residents between meals. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents.
- The DON and Social Services Director educated all staff that only dietary staff is permitted to serve hot beverages, with the exception that only a nurse on duty is permitted to serve hot beverages to residents.
- The DON educated nurses on correct process for temping and serving hot beverages. Hot beverages must be temped and logged prior to serving to residents. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents.
- Signs were placed at both kitchen doors by the Registered Dietitian, stating only nurses can serve hot beverages to residents. The Activity Director was instructed to inform residents of this at the next Resident Council Meeting.
- The DON assessed all current residents for safe handling of hot beverages using the Hot Liquid Evaluation. Occupational Therapy was then notified for safety screening per written order for those deemed necessary. The Dietary department was notified to use spill proof cups via Dietary Communication forms for those deemed necessary. Tray tickets and care plans were updated as needed by the Registered Dietitian.
- The Dietary Manager/designee will observe dietary staff at all meals to ensure proper temping and logging of hot beverages until assured that all dietary staff know the proper process.
- The Dietary Manager/designee will audit temperature logs daily to ensure the process is being followed and temperatures are at approved levels for hot beverages.
- The NHA will audit hot beverage logs to ensure compliance.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide palatable food products to 66 residents, which increased the likelihood of decreased food acceptance and nutritional decline. Observations and temperature checks revealed that food items were not maintained at safe and appetizing temperatures. For instance, the temperature of 2% milk was recorded at 47.8°F, which is above the recommended maximum of 41°F. Similarly, other food items like Capri Blend Vegetables and Garlic Toast were served below the required temperature of 135°F. These temperature discrepancies were observed during the delivery of food trays to different halls using non-insulated transport carts. Interviews with residents highlighted dissatisfaction with the quality and temperature of the food. One resident described the mashed potatoes as mushy and the scrambled eggs as overcooked and rubbery. Another resident expressed dissatisfaction with the overcooked chicken and unappetizing breakfast options like sausage, gravy, and biscuits. These comments indicate that the food was not only served at incorrect temperatures but also lacked palatability, affecting the residents' dining experience. The facility's policies on maintaining a sanitary tray line and hot liquid safety were reviewed, revealing a lack of adherence to proper food handling and temperature maintenance guidelines. The policy emphasized the importance of monitoring food temperatures throughout meal service to prevent foodborne illnesses. However, the observed practices did not align with these guidelines, as evidenced by the recorded temperatures and resident feedback. The failure to maintain appropriate food temperatures and palatability contributed to the deficiency identified by the surveyors.
Deficiencies in Food Service Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain proper cleanliness and maintenance standards in its food service operations, affecting 66 residents. During an inspection, several deficiencies were noted, including a missing tile surface beneath a reach-in cooler, a loose ice machine door, and a malfunctioning walk-in cooler door closer. These issues were not addressed promptly, increasing the risk of cross-contamination and bacterial harborage. Additionally, opened containers of sour cream and cottage cheese were found without proper date marking, violating the FDA Model Food Code requirements for time/temperature control for safety food. Further observations revealed that the Cobra Head beverage dispensers and the interior of the Employee Breakroom Whirlpool refrigerator were soiled with accumulated food residue. The facility's policies on date marking and maintaining a clean dietary department were not effectively implemented, as evidenced by the lack of date marking on food products and the unclean state of food-contact surfaces. These lapses in adherence to professional standards and facility policies contributed to the increased likelihood of resident foodborne illness.
Failure to Complete Competency Evaluations for LPNs
Penalty
Summary
The facility failed to ensure that two out of five Licensed Practical Nurses (LPNs) had completed the required initial and annual competency evaluations. This deficiency was identified through interviews and record reviews. Specifically, the personnel records for LPN L and LPN DD did not demonstrate completion of the necessary competency evaluations. LPN L's file lacked documentation of both a new hire competency and an annual skills competency, while LPN DD's file did not show completion of a competency evaluation after orientation or an annual evaluation. The Director of Nursing (DON) confirmed during interviews that all nursing staff are supposed to receive competency evaluations after orientation and annually, which are completed by observing the skills performed. However, the facility's policy on Competency Evaluation was found to be lacking, as it did not include implementation or review dates, and it stated that subsequent and/or annual competency evaluations are determined by the facility's assessment and job performance evaluations. Despite attempts to locate the missing documents, the facility was unable to provide the required annual skills competency evaluations for LPN L and LPN DD by the time of the survey exit.
Facility Maintenance and Cleaning Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 66 residents and increasing the likelihood of cross-contamination, bacterial harborage, and decreased air quality. During an environmental tour, several deficiencies were noted, including damaged drywall in the lobby, non-functional return-air-exhaust ventilation in the soiled utility room, and etched, scored, and particulate surfaces on exit doors in the main dining room, food production kitchen, and sunroom. Additionally, a slow-draining hand sink basin was observed in a resident's restroom. Interviews and record reviews revealed that the facility's maintenance work order system did not have specific entries related to these maintenance concerns for the last 60 days. The facility's policies and procedures for cleaning and disinfecting resident rooms and maintenance services were reviewed, indicating that housekeeping surfaces should be cleaned regularly and maintenance should ensure the building is safe and operable at all times. However, the lack of documented work orders suggests a failure to address these issues promptly.
Failure to Provide Timely Financial Statements
Penalty
Summary
The facility failed to provide timely financial statements to a resident's responsible person, resulting in a lack of information about the resident's personal funds. The resident, who was admitted to the facility with multiple diagnoses including severe cognitive impairment, had a financial account managed by the facility. The responsible person, who held the Durable Power of Attorney for the resident, reported not receiving any quarterly financial statements from the facility, which was confirmed during a telephone interview. The Business Office Manager explained that the facility used a third-party contractor to manage resident accounts and that statements were supposed to be mailed to the facility and then forwarded to the residents or their responsible parties. However, the Business Office Manager was unable to provide documentation that the statements had been mailed to the resident's responsible person and admitted that the facility had not received or mailed out quarterly statements for an undetermined amount of time. A review of the resident's financial statement showed a current balance, indicating that statements should have been regularly provided.
Failure to Notify Physician of Burn Condition Change
Penalty
Summary
The facility failed to notify the physician of a change in the tissue appearance of a burn sustained by a resident. The resident, who had multiple sclerosis and severe protein-calorie malnutrition, reported spilling hot coffee on his leg, resulting in a burn. Initially, the burn was treated with medihoney and covered with a dressing. The burn was assessed as a second-degree burn with blisters and a raised, red area. However, over time, the burn's appearance changed, with more dead tissue present, resembling a third-degree burn. Despite these changes, there was no documentation of the physician being notified about the change in the burn's appearance. The Assistant Director of Nursing acknowledged the lack of documentation and believed medihoney was still appropriate for treatment. The wound provider later assessed the burn and changed the treatment to silvadene. The failure to notify the physician of the change in the burn's condition constitutes a deficiency in the facility's care for the resident.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare coverage to a resident, identified as Resident #14, who was admitted with multiple health conditions including type 2 diabetes, weakness, and heart disease. The resident's payment source changed from Medicare to pending Medicaid, but the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) before the termination of Medicare Part A services. This oversight occurred despite the resident being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The deficiency was identified during a review of the resident's medical records and an interview with the facility's social worker, who was responsible for providing these notices. The social worker acknowledged the responsibility but could not explain why the required notifications were not given to the resident. This lapse in procedure resulted in the resident not being informed of the change in coverage and potential financial liability for services not covered by Medicare.
Failure to Provide Wound Care Per Physician Orders
Penalty
Summary
The facility failed to provide wound care per physician orders for a resident, resulting in the likelihood of infection and delayed wound healing. The resident, who was cognitively intact, had multiple diagnoses including heart failure, high blood pressure, end-stage renal disease requiring dialysis, lung disease, skin tears, and moisture-associated skin damage. Observations revealed that the resident had heavily saturated dressings on both arms, dated five days prior to the observation, indicating a lack of timely wound care. The physician's orders required wound care to be performed every Monday, Wednesday, and Friday, but the Treatment Administration Record (TAR) showed discrepancies in the documentation of these treatments. Interviews with nursing staff revealed confusion and miscommunication regarding the responsibility for changing the dressings, with one nurse documenting a code to avoid a red flag in the electronic medical record, and another nurse not completing the treatment due to a lack of assistance. This lack of adherence to the care plan and documentation led to the deficiency.
Failure to Provide Restorative Ambulation Services
Penalty
Summary
The facility failed to provide restorative ambulation services to a resident, resulting in sadness and fear of losing the ability to walk. The resident, who had a history of traumatic brain injury, stroke with hemiplegia, seizure disorder, anxiety, and depression, expressed a desire to participate in therapy but was informed that insurance would not cover it. Despite recommendations from the Rehabilitation Director for staff to assist the resident with ambulation in the hallway, the facility did not have a restorative nursing program in place, and the resident was not walked outside of her room. Interviews with staff, including CNAs and the Director of Nursing, revealed that there were no instructions or programs for ambulating the resident in the hallway. The resident's care plan did not include any directives for ambulation assistance, and staff confirmed that they did not supervise or assist the resident with walking outside her room. The lack of a structured walking program and the absence of restorative nursing activities contributed to the resident's emotional distress and fear of losing her mobility.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet to a resident with multiple sclerosis and severe protein-calorie malnutrition. The resident, who was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status, experienced a significant weight loss of 16.05% from January to July 2024. A physician's order required the resident to receive double protein portions at meals, starting in March 2024. However, during an observation in July 2024, the resident's lunch tray did not include the prescribed double protein portions, despite the order being highlighted on the tray ticket. This oversight was confirmed by a registered dietitian who observed the meal before it was consumed.
Failure to Provide Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident who required the use of a CPAP machine. During an observation, the resident was found not using the CPAP machine because it was missing a part. The resident, who had a moderate cognitive impairment, was diagnosed with sleep apnea, high blood pressure, Parkinsonism, anxiety, depression, dementia, and seizure disorder. Despite these conditions, there were no physician orders for the use of a CPAP machine, and the facility was unaware of the resident's need for it until they contacted the resident's power of attorney.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of 26 opportunities, resulting in an error rate of 11.54%. Two residents were involved in these errors. Resident #58, who has a range of medical conditions including dysphagia and anxiety, was not observed consuming her prescribed MiraLAX solution. The LPN left the medication on the resident's over-bed table without ensuring it was taken, contrary to facility policy which requires the nurse to remain with the resident until the medication is swallowed. Resident #60, who has a feeding tube and conditions such as cerebral infarction and hemiplegia, received her medications incorrectly. The LPN crushed and mixed Oxycodone and Gabapentin together before administering them through the feeding tube, which is against the facility's policy that mandates each medication be administered separately with a flush of water before and after each dose. These actions were not in compliance with the facility's medication administration policies, as confirmed by the Director of Nursing during an interview.
Failure to Honor Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to honor the food preferences and dietary restrictions of a resident, identified as Resident #39, who was admitted with diagnoses including dependence on renal dialysis and diabetes. The resident, who was cognitively intact, reported that her meal tray ticket specified her dietary restrictions, including an allergy to peppers and an intolerance to tomato products. Despite these specifications, she was served meals containing these ingredients, which aggravated her gallbladder and upset her stomach. Additionally, the resident reported that when she requested an alternate meal, she did not receive the accompanying dessert or side items. The resident also experienced issues with meal provision on her dialysis days. She was supposed to receive a sack breakfast before leaving for dialysis early in the morning, but the kitchen reportedly did not provide this, leaving her without food until her return around 11:00 AM. The Registered Dietitian (RD) had communicated the resident's breakfast preferences to the kitchen, including items like dry cereal, hard-boiled eggs, and yogurt, to be prepared the night before dialysis days. However, the RD was unaware if these items were actually being provided to the resident.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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