Majestic Care Of Flushing
Inspection history, citations, penalties and survey trends for this long-term care facility in Flushing, Michigan.
- Location
- 540 Sunnyside Drive, Flushing, Michigan 48433
- CMS Provider Number
- 235132
- Inspections on file
- 33
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Majestic Care Of Flushing during CMS and state inspections, most recent first.
Two residents who required assistance with ADLs were found to have long, soiled fingernails due to the facility's failure to provide routine nail care. One resident with multiple medical conditions and contractures had neglected nails despite care plan notes about scratching and skin breakdown risk, while another resident with dementia and arthritis had unclean nails and no documentation of recent nail care. Staff acknowledged nail care should occur during showers, but records did not confirm this was done.
A resident with a coccyx pressure ulcer did not receive wound care as ordered, with observations revealing a dressing unchanged for several days despite staff documentation indicating daily care. The resident reported infrequent dressing changes and was seen scratching the wound, leading to bleeding. Nursing staff had initialed wound care as completed without performing the task, and there was no documentation of care refusal.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
Surveyors identified multiple deficiencies in kitchen sanitation and equipment maintenance, including unclean food preparation tools, malfunctioning dishwashing equipment, and inadequate cleaning of kitchen fixtures. Staff interviews revealed inconsistent adherence to cleaning schedules and a lack of clear responsibility for maintaining sanitary conditions.
Surveyors found that the facility failed to implement a comprehensive infection prevention and control program, with staff not performing hand hygiene, missing hand sanitizer dispensers, and soiled equipment. The infection control nurse was unfamiliar with surveillance processes, and infection data was incomplete or inconsistent. In one case, a resident with a wound infection was not included in surveillance records or treated, and another resident's potential bed bug exposure was handled by maintenance staff instead of nursing, with no proper documentation or follow-up. Covid-19 cases were not consistently tracked or reported, and there was no evidence of outbreak investigation or health department notification.
The facility did not properly implement or document its Antibiotic Stewardship Program, as shown by incomplete infection surveillance records, missing laboratory data, and lack of documentation for antibiotic use in four residents. Several residents received antibiotics without clear evidence of infection, appropriate assessments, or monitoring, and staff were unable to explain or justify antibiotic choices due to missing or incomplete records.
A resident's bathroom was found with a large hole in the baseboard, a cracked toilet, and unsanitary conditions, while an environmental tour revealed widespread issues such as soiled linens on the floor, corroded sinks, missing emergency equipment, dirty vents, and unclean common areas. These deficiencies resulted in an unsafe, unsanitary, and uncomfortable environment for all residents and staff.
Multiple residents, all dependent on staff for ADLs and with significant medical needs, were left without accessible call lights or experienced long delays in staff response, leading to unmet toileting and personal care needs. Family members and residents reported staff inaction, and observations confirmed residents were left soiled, exposed, or unable to summon help, resulting in distress, skin irritation, and embarrassment.
Multiple residents who were dependent on staff for ADLs did not consistently receive showers, grooming, or hygiene care as required by their care plans. Observations and interviews revealed missed showers, unwashed hair, body odor, dirty nails, and soiled clothing, with staff citing workload and staffing shortages as reasons for missed care. Documentation did not reflect resident refusals, and residents expressed dissatisfaction and embarrassment over the lack of personal care.
Multiple residents reported significant delays in call light response, missed showers, and untimely incontinence care due to inadequate staffing. Staff interviews and facility records confirmed frequent call-ins, inability to secure coverage, and reliance solely on internal staff, resulting in unmet ADL needs and resident frustration.
Three residents experienced missed showers and inadequate personal hygiene due to the facility's failure to follow or revise ADL care plans. Residents reported infrequent bathing, unkept appearances, and dissatisfaction with care, while records showed a lack of individualized scheduling, incomplete documentation of preferences, and no recorded refusals despite missed showers.
A resident with dementia, dysphagia, and depression, who required assistance with ADLs and had impaired cognition, was repeatedly found in bed with no accessible activities and expressed ongoing boredom. Despite a care plan indicating preferences for independent activities, board games, and music, only limited group activities were documented, and there was no activity cart or consistent provision of materials of interest. The resident's environment lacked accessible engagement, and basic needs such as access to the TV and glasses were not met.
A resident with severe cognitive impairment, a history of falls, and multiple comorbidities was observed ambulating and toileting without staff assistance, despite care plan interventions requiring supervision and help with these activities. The resident was left unsupervised, stood from a wheelchair without brakes locked, and exposed themselves to the hallway while attempting to use the bathroom. Staff did not consistently follow care-planned interventions, resulting in unassisted ambulation and toileting for the resident.
A resident with multiple respiratory and cardiac conditions was found with a CPAP mask, tubing, and head strap that were visibly soiled with brown buildup over several days. Despite orders and documentation indicating weekly cleaning, the equipment remained dirty, and the resident reported it was not being cleaned. Staff confirmed the equipment was dirty, demonstrating a failure to provide appropriate respiratory care.
Two residents reported receiving cold, unappetizing meals that did not meet their stated preferences, with one resident also lacking regular access to fresh water. Multiple residents at a council meeting unanimously described ongoing issues with food quality, meal delivery delays, and unfulfilled menu choices, with staff interviews and observations confirming these deficiencies.
Three residents with recent amputations or surgical wounds did not receive timely or adequate wound assessment, monitoring, or treatment. One resident's surgical site was not assessed for two weeks, leading to infection and further surgery. Another resident's amputation site was not assessed or monitored until several days after admission, and care plan interventions were incomplete. A third resident's toe amputation wound was not consistently treated or documented, with no physician order in place despite ongoing wound care.
A resident with a PEG tube did not receive proper assessment and monitoring of the insertion site, resulting in a reddened, painful area that was noticed by family rather than staff. There was no documentation of PEG site care or assessment, no physician order for PEG care upon admission, and the resident's admission weight was not obtained until five days after arrival. Enteral nutrition orders were delayed, and the resident initially received a different formula than indicated. Facility policies for enteral feeding and weight monitoring were not followed.
A resident with multiple medical conditions did not receive several prescribed medications on time due to delays in pharmacy delivery, lack of emergency medication drops, and incomplete use of backup medication supplies. The DON confirmed that some medications were not administered as ordered and that the facility did not obtain medications from local pharmacies while waiting for contracted pharmacy deliveries.
A resident with multiple health conditions was admitted to a facility with pressure ulcers that were not documented by staff. Despite hospital records indicating the presence of these ulcers, the facility's initial assessment failed to identify them, leading to a deficiency in care. The facility's policy on wound prevention was not adequately followed, resulting in a lack of proper documentation and intervention for the resident's pressure ulcers.
A resident with end-stage renal disease did not receive scheduled dialysis treatments due to coordination issues at the facility, leading to her being sent to the ER with hallucinations and confusion. Despite attempts to arrange dialysis, the facility failed to monitor the resident's condition adequately, resulting in a five-day lapse in treatment. The facility's policy for monitoring postponed dialysis was not followed, as no weight or lab work was conducted to assess the resident's kidney function.
A resident with mental health issues attempted suicide twice due to inadequate supervision at an LTC facility. Despite requiring 1:1 supervision, the facility failed to provide continuous monitoring, leading to two incidents where the resident attempted strangulation. Staff interviews revealed miscommunication and a lack of clear policies to address suicidality.
The facility failed to provide adequate pressure ulcer care for three residents, leading to wound deterioration and infection. A resident's coccyx wound worsened due to inconsistent treatment orders and lack of proper care, resulting in sepsis. Another resident had a foot dressing that was not dated or initialed, and a third resident's heel protectant boots were not used as ordered, with dressings also lacking proper documentation.
Two residents in a LTC facility sustained injuries due to inadequate supervision and failure to follow post-fall assessment protocols. One resident, an active exit seeker, was startled by staff, resulting in a fall and head injury requiring emergency treatment. The facility did not document required neurological assessments post-fall. Another resident with dementia fell and fractured his hand while visiting another resident's room, against facility guidance. The care plan lacked increased supervision measures, contributing to the incident.
The facility failed to maintain an accurate infection control program, with inconsistencies in tracking infections and outdated policies. Discrepancies were noted in infection counts and antibiotic use, with some infections treated without meeting criteria. The infection preventionist was unaware of the need for education on infection increases, and the DON confirmed outdated policies and lack of audits on antibiotic stewardship.
The facility failed to provide scheduled showers for four residents, leading to a deficiency in ADL care. A resident with a self-care deficit due to obesity and amputation missed scheduled showers without documentation. Another resident with physical limitations reported missing showers due to staff shortages. Two residents refused showers multiple times, but no alternative bathing options were documented. The facility's ADL policy was not adhered to, indicating a failure to prevent deterioration in residents' abilities.
A facility's medication error rate exceeded 5% when an LPN was unable to administer pantoprazole and Entresto to a resident due to unavailability in the medication dispensing machine. Despite ordering the medications the previous day, they were not delivered by the pharmacy, leading to an 8% error rate.
The facility failed to properly label and secure medications, resulting in several deficiencies. An unlocked medication cart was found unattended with loose medications, and expired or undated medications were discovered in various locations. Facility policies on medication storage and administration were not followed, increasing the risk of decreased efficacy and potential drug diversion.
The facility failed to maintain sanitary conditions in the kitchen, with staff not adhering to hygiene practices like wearing hair and beard nets. Observations showed food debris on floors, improper food storage, and inadequate cleaning. A cook used the same gloves for multiple tasks without washing hands, and structural issues like an unfinished doorway and open drain were noted, posing health risks to residents.
The facility failed to maintain an effective vaccination program for four residents, with issues including missing consents, unadministered vaccines despite signed consents, and outdated policies. Interviews revealed that the infection preventionist lacked access to the vaccination database, and the DON acknowledged the need for better processes. An LPN could not explain why a resident did not receive vaccinations despite signed consents.
The facility failed to maintain essential equipment, including beds and wheelchairs, in safe condition, affecting multiple residents. A resident nearly fell due to an unstable bed, while another faced frustration with a non-functional bed remote. A wheelchair with loose wheels and a cracked overhead light fixture were also reported but remained unaddressed until surveyor intervention. The maintenance staff and administration were unaware of these issues, highlighting a lack of communication and systematic checks.
The facility failed to ensure dignified care and timely call light responses for several residents, leading to prolonged incontinence and frustration. Residents reported extended wait times for assistance, with some experiencing exposure and lack of privacy. A CNA refused to assist a resident, citing workload, further highlighting the facility's deficiencies in maintaining resident dignity and care.
A resident's Tramadol medication was misappropriated due to discrepancies in the controlled substance log and MAR. The facility's failure to accurately document and reconcile medications led to one pill being unaccounted for. The nurse involved was suspended pending further investigation.
A resident experienced a fall resulting in fractures to the right hand, which was not reported to the State Agency as required. The resident was found with an ice-wrapped hand and transferred to the ER, where fractures were confirmed. The facility's DON confirmed the failure to report the injury, violating the facility's Abuse Prevention Program.
A resident with dementia and severely impaired cognition sustained an injury of unknown origin, resulting in fractures to the hand. The facility failed to conduct a thorough investigation, as required by its policies, by not obtaining witness statements from staff who observed the incident. This oversight led to a deficiency with the potential for undetected abuse or neglect.
Two residents with PICC lines in an LTC facility were found to have non-occlusive dressings and lacked initial measurements upon admission. The facility's policy of weekly dressing changes was not followed, and there were discrepancies in documentation and untimely monitoring orders. The management acknowledged these deficiencies.
The facility failed to obtain informed consents for psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. One resident received an antipsychotic for eight weeks without proper consent from her guardian, while another was given multiple psychotropic medications without any signed consents. The facility's policy did not address informed consents, contributing to the oversight.
A facility failed to adhere to professional standards in medication administration and documentation for two residents. One resident had a discrepancy in the controlled substance log for Tramadol, with a missing pill unaccounted for. Another resident was offered Melatonin without a proper order, and the nurse involved backdated entries in the medical record. The nurse had a history of medication administration violations, and facility policies were not followed, resulting in inaccurate documentation.
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. The Social Work Director and Director of Nursing acknowledged the issue and mentioned access problems with the OBRA system. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
Failure to Provide Routine Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that routine nail care was provided for two residents who required assistance with activities of daily living (ADLs). One resident, with a history of bipolar disorder, anxiety, contractures, heart disease, neuropathy, and a recent finger fracture, was observed to have long, discolored, and jagged fingernails on a contracted hand. The care plan noted the resident's risk for skin breakdown and a tendency to scratch, but did not include specific interventions for nail care or alternative plans to address nail maintenance. The resident expressed concern about the condition of his nails, noting they were curling under, and agreed to have them trimmed when offered by staff. Documentation did not reflect consistent nail care assistance as part of his ADL support. Another resident, diagnosed with dementia, arthritis, gout, heart failure, and other chronic conditions, was observed with long, unclean fingernails and stated she needed her nails done. The care plan indicated that nail care should be provided on bath days and as necessary, but review of shower documentation showed the last shower occurred a week prior, with no record of nail care being completed. Staff confirmed that nail care was expected to be performed during showers, but there was no evidence this was done. The facility was unable to provide a nail care or shower policy upon request during the survey.
Failure to Provide Wound Care as Ordered and Inaccurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple medical conditions, including a pressure ulcer on the coccyx. Physician orders specified daily cleansing of the coccyx wound with normal saline, application of collagen wound filler, and comfort foam, to be changed every day and as needed. However, during observation, the resident's wound dressing was found to be dated four days prior, shriveled, and appeared to have not been changed as required. The resident reported that the dressing was changed about once a week, and was observed scratching the wound, causing bleeding. Review of the Medication Administration Record/Treatment Administration Record showed that staff had initialed daily completion of wound care, including on days when the dressing had not been changed. Interviews with nursing staff and the Director of Nursing revealed that some nurses had documented completion of wound care without actually performing the dressing change. There was no documentation in the progress notes to indicate that the resident had refused care on the days in question. The facility's wound care policy was requested but not provided prior to the survey exit.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Maintain Sanitary Kitchen and Equipment Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not ensure that kitchen equipment and fixtures were in good working condition. During a kitchen tour, surveyors observed multiple instances of unclean food preparation equipment, including kitchen knives with dried food, a can opener with a black dried substance, plates with food particles, and a steam table with crumbs and dried food. Additional observations included a professional oven and microwave with dried food residue, and utensils with broken pieces and dried batter. The kitchen's cleaning schedules indicated that these items were supposed to be cleaned daily or weekly, but the observed conditions did not align with these schedules. Surveyors also found that the large dishwasher was malfunctioning, spraying hot water onto the floor and staff due to a loose water shield and damaged curtains, with no safety mats in place despite their availability. The three-compartment sink was leaking water from the faucet, and maintenance staff were unaware of the issue. The walk-in cooler fan covers were covered in black dust and dirt, and there was no documentation or set schedule for their cleaning. The floor drain under the cook's sink was filled with dirt, dust, and food items, and the milk cooler had dried milk residue both inside and on the floor. Metal pans with significant wear were found on the clean pan rack, and the cleaning of walk-in fan covers was delayed for several days after initial observation. Interviews with dietary and maintenance staff revealed a lack of awareness or adherence to cleaning responsibilities and schedules. Staff acknowledged that certain equipment should be cleaned after each use or weekly, but these practices were not consistently followed. Maintenance staff also indicated that they relied on dietary staff to notify them about cleaning needs for certain equipment, such as the walk-in cooler fan covers, rather than following a set schedule.
Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Surveyors observed that hand hygiene practices were not followed by staff, including dietary and nursing assistants, who did not use hand sanitizer or wash hands before leaving residents' rooms after delivering food or providing care. Hand sanitizer dispensers were missing from some resident rooms, and staff were seen touching contaminated surfaces and moving between residents without performing hand hygiene. Additionally, soiled room divider curtains and lack of accessible hand hygiene equipment were noted. The infection control (IC) program lacked accurate and complete outcome and process surveillance. The IC nurse was unfamiliar with the facility's surveillance processes, could not explain discrepancies in infection data, and was unaware of the water management plan. Infection surveillance documentation was incomplete, with missing summaries and analyses, inconsistent line listings, and lack of documentation for some infections. For example, a resident with a wound culture positive for infection was not included on the line list and did not receive documented treatment. Another resident's infection was listed twice with conflicting information, and there was no documentation of whether infections met McGeer criteria. Covid-19 cases were not consistently tracked or reported, and there was no evidence of health department notification or outbreak investigation. The facility also failed to respond appropriately to a staff report of potential bed bugs. When aides reported possible bed bugs in a resident's bedding, the maintenance director, who lacked clinical credentials, conducted a skin assessment instead of nursing staff. No nursing skin assessment or follow-up documentation was found in the resident's medical record. The pest control company was called and then canceled by the maintenance director without proper investigation or documentation. Staff were not informed of the incident during shift reports, and there was no clear policy or procedure for handling such situations. Overall, the facility's infection control program was disorganized, with inadequate documentation, lack of staff education, and insufficient monitoring of both residents and staff for infections.
Failure to Implement and Document Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program, as evidenced by incomplete documentation, lack of analysis, and insufficient monitoring of antibiotic use for four residents reviewed for antimicrobial treatment. Infection control documentation for January 2025 did not include a summary or analysis of infections, and the Monthly Infection Surveillance Report was missing critical information, such as whether infections met McGeer’s Criteria for 15 out of 31 cases. The infection control nurse (IC RN K) was unable to explain missing data or confirm the appropriateness of antibiotic treatments due to incomplete records and lack of laboratory results. For one resident treated for a UTI, the line listing omitted the date antibiotic treatment was started, did not specify if the infection was facility or community acquired, and lacked laboratory testing results. The IC nurse could not explain why certain organisms were not documented or confirm if the prescribed antibiotic was appropriate, as sensitivity data was missing. Another resident was treated for a UTI, but the facility lacked a culture and sensitivity report, and the infection was incorrectly classified as community acquired when it was actually facility acquired. The IC nurse could not evaluate the appropriateness of antibiotic treatment due to missing documentation and assessments. Additional deficiencies included a resident started on two antibiotics after a podiatry visit without any progress notes, assessment, or documentation of infection signs and symptoms. The IC nurse and DON were unable to provide documentation or rationale for the antibiotic orders, with the DON indicating antibiotics may have been prescribed prophylactically. Another resident was prescribed a prolonged course of antibiotics without documentation of the infection being treated, the organism involved, or monitoring of ongoing antibiotic use. The resident was not included in the infection control line listing, and the facility could not provide supporting documentation for the extended antibiotic therapy.
Widespread Environmental Deficiencies Compromise Facility Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and staff, as evidenced by multiple observations throughout the building. One resident was found to have a bathroom with a large hole in the baseboard exposing cement and debris, a cracked toilet base, and an unknown brown substance around the toilet. The resident expressed concern about potential falls due to the bathroom's condition. Additional issues in the same bathroom included missing baseboards and exposed cement block above the hand sanitizer dispenser. During an environmental tour, numerous deficiencies were identified in various areas of the facility. These included clean linen and gowns on the floor, soiled vents blowing onto uncovered clean linen, corroded sink drains, uncovered suction equipment, dead sewer flies, soiled gloves on the floor, missing emergency pull cord light, missing shampoo dispenser handle, dusty vents, and unlabelled body wash. Other areas had stained or bowing ceiling tiles, holes in air vent grates, hazardous chemicals at bedsides, damaged privacy curtains, exposed wood and scratched walls, soiled sinks, missing tiles, clutter, and dirty equipment. The resident activity room and laundry room were also found to be unclean, with debris, cobwebs, soiled blinds, and standing water present. The facility's job descriptions for the Housekeeping Supervisor and Maintenance Director require them to ensure a clean, orderly, safe, and attractive environment, as well as efficient functioning and upkeep of the building. However, the observed conditions indicate a failure to meet these responsibilities, resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and the public.
Failure to Ensure Resident Dignity and Timely Assistance with Call Lights and Toileting
Penalty
Summary
Surveyors identified multiple failures by facility staff to honor residents' rights to dignity, self-determination, and communication. Several residents, all dependent on staff for activities of daily living (ADLs) due to complex medical conditions such as heart disease, kidney disease, cognitive impairment, and mobility limitations, were observed without accessible call lights or experienced extended call light response times. In some cases, residents were unable to reach their call lights, were unaware of their location, or reported that staff did not respond in a timely manner. Family members corroborated these accounts, with one family member stating they had to provide incontinence care themselves due to staff inaction. Resident Council meeting notes further documented widespread complaints about delayed call light responses, with reports of waits exceeding an hour and staff not meeting residents' needs. Additional deficiencies were observed in the provision of toileting and personal care. One resident, dependent on staff for toileting and personal hygiene, was left soiled and told to wait for assistance until after eating, despite having both urinary and fecal incontinence. The resident was observed attempting to eat without adaptive equipment, with food spilled on their clothing and a strong odor of bowel movement present. Staff were unable to identify who delivered the food tray or provide timely incontinence care, contrary to the resident's care plan, which required routine checks and assistance with toileting and eating. Another resident was observed with their pants down, exposed to the hallway while attempting to access the bathroom independently, indicating a lack of timely staff assistance with toileting and a failure to maintain the resident's dignity and privacy. These incidents, supported by resident interviews, observations, and care plan reviews, resulted in residents experiencing fear of abandonment, anger, skin irritation from prolonged exposure to urine and feces, and embarrassment.
Failure to Provide Consistent ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), including bathing, grooming, and hygiene, for multiple residents who were dependent on staff for these services. Several residents did not receive scheduled showers or bed baths as documented in their care plans, with records showing missed showers on specific dates and no documentation of resident refusals. Observations and interviews revealed residents with unwashed hair, body odor, dirty or untrimmed nails, and soiled clothing, indicating a lack of consistent personal hygiene care. Residents expressed dissatisfaction and distress regarding the lack of assistance with ADLs. Some reported that showers were not given regularly, and that staff would often tell them to wait for the next shift or only provide a quick wash with a wet cloth. Staff interviews confirmed that showers and other ADL tasks were sometimes missed due to staffing shortages or workload, and that not all residents' preferences or needs were being met as outlined in their care plans. In several cases, there was no documentation of refusals or alternative care provided when showers were missed. The affected residents had significant medical histories and cognitive impairments, making them reliant on staff for daily care. Observations included residents with dried food and wet spots on clothing, long and dirty fingernails, unshaven facial hair, and unchanged or soiled clothing. These findings were corroborated by both staff and resident interviews, as well as review of care plans and ADL task sheets, which consistently showed gaps in the provision of required personal care services.
Failure to Provide Adequate Staffing for Resident ADL Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the Activities of Daily Living (ADL) needs of residents, as evidenced by multiple resident complaints and staff admissions. During a Resident Council meeting, all sixteen residents present unanimously reported a shortage of staff, resulting in delayed call light responses, missed showers, and untimely incontinence care. Residents described waiting extended periods—sometimes up to two hours—for assistance, with some staff turning off call lights without providing the requested help or telling residents to wait until the next shift for care. Several residents reported having to wait so long for assistance that they experienced incontinence or had to seek help at the nurse station themselves. Interviews with residents further corroborated these issues, with consistent reports of insufficient staff, poor attitudes among aides, and a lack of empathy. Residents described staff as being overworked, with some aides refusing to adjust their routines to meet residents' immediate needs. Night shift staffing was particularly problematic, with reports of residents not receiving water, being left unattended for long periods, and staff failing to return after initially responding to call lights. Some residents also noted that showers were infrequent and dependent on which aide was working, and that some aides were not adequately trained to provide proper shower care. Staff interviews and facility records confirmed the staffing challenges. The staff scheduler acknowledged frequent call-ins and an inability to secure adequate coverage, as the facility does not use agency staff and relies solely on internal staff. The Nursing Home Administrator admitted to ongoing staff turnover and issues with staff performance, including some staff hiding or not doing their work. The facility's call light audits only tracked response times, not whether the requested service was actually provided. Observations by the surveyor also noted staff complaints about being short-staffed. The facility's own policies and job descriptions require sufficient staffing and competency in ADL care, but these standards were not being met, as evidenced by the consistent resident and staff reports.
Failure to Follow and Revise ADL Care Plans for Bathing and Hygiene
Penalty
Summary
The facility failed to follow and/or revise care plans for Activities of Daily Living (ADL) related to bathing and personal hygiene for three residents. Observations and interviews revealed that residents experienced missed showers and unkept appearances, including body odor, without documented refusals or individualized care plans reflecting their preferences. For example, one resident was observed to have body odor on multiple occasions and reported that showers were not given regularly. The care plan indicated staff assistance for sponge baths twice weekly and as needed, but did not specify individualized days or whether a sponge bath was the resident's preferred method of bathing. Shower records showed only four showers in a 30-day period, and there was no documentation of refusals in the progress notes. Another resident reported inconsistent assistance with bathing and hygiene, stating that some staff were helpful while others were not, and that there were staffing shortages on certain shifts. The care plan called for staff assistance with showers twice weekly and as needed, but again lacked individualized scheduling or documentation of resident preferences. Shower records indicated missed showers on specific days, with no documented refusals. A third resident expressed dissatisfaction with receiving only quick bed washes instead of showers, which he did not like. The care plan included staff assistance for showers and instructions to reapproach and document refusals, but only two showers were recorded in a 30-day period, and no refusals were documented in the progress notes.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities to meet the needs of a resident, resulting in complaints of boredom and having nothing to do. Observations revealed that the resident was often found resting in bed with the television on but with the volume off and the remote out of reach. The resident expressed feeling bored and stated there was nothing to do. Interviews with the Activity Director indicated that while some one-on-one activities and food-related group activities were offered, there was no activity cart available to provide a variety of in-room activity choices. Documentation showed that only four activities were provided in the past 30 days, and the resident's care plan indicated a preference for self-directed and independent activities, as well as board games and country music, but there was little evidence these preferences were being met. The resident had diagnoses including dementia, dysphagia, and depression, required assistance with activities of daily living, and had impaired cognition. Despite these needs, the resident's care plan interventions, such as providing materials of interest and assistance to activity functions, were not consistently implemented. Multiple observations confirmed that the resident's environment lacked accessible activities, and basic needs such as access to the television and glasses were not addressed, contributing to the resident's ongoing complaints of boredom.
Failure to Provide Supervision and Assistance with Toileting and Ambulation
Penalty
Summary
The facility failed to follow care-planned interventions and provide adequate supervision and assistance with toileting for a resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, visual loss, and chronic kidney disease. Observations revealed that the resident was left unsupervised in their room, stood up from their wheelchair without locking the brakes, and ambulated independently to their closet and bathroom on multiple occasions. The resident was also observed to change their socks and slippers and propel themselves in the wheelchair without staff assistance. During one incident, the resident exposed themselves to the hallway while attempting to use the bathroom unassisted, and the wheelchair rolled and struck the bathroom door, creating a potential hazard. Record review indicated that the resident had several unwitnessed falls in recent months and required staff assistance for activities of daily living, including ambulation, transfers, and toileting, as documented in their care plan. Despite these interventions being in place, staff did not consistently provide the required supervision or assistance, resulting in the resident performing activities independently that should have been assisted. Interviews with staff confirmed the resident's poor safety awareness and cognitive impairment, further emphasizing the need for adherence to care-planned interventions.
Failure to Maintain Clean CPAP Equipment for Resident
Penalty
Summary
A resident with diagnoses including obstructive sleep apnea, heart failure, and chronic obstructive pulmonary disease was observed with visibly soiled CPAP equipment over multiple days. The CPAP nasal mask, tubing, and head strap all had significant brown buildup, and the resident reported that nobody cleaned the equipment. The resident required assistance with activities of daily living and had impaired cognition. Despite physician orders specifying weekly cleaning of the CPAP tubing and documentation indicating the cleaning was completed, the equipment remained dirty upon repeated observations. Record review confirmed that the treatment administration record was marked as completed for the required weekly cleaning, yet the equipment was still visibly soiled. Staff acknowledged the presence of brown buildup and that the equipment was dirty, indicating a failure to provide safe and appropriate respiratory care as ordered. The deficiency was identified through direct observation, resident interview, and review of medical and treatment records.
Failure to Provide Palatable and Timely Meals per Resident Preferences
Penalty
Summary
The facility failed to provide palatable, appetizing, and per-preference meals at safe and appropriate temperatures for multiple residents. One resident, who is bed bound, alert, and dependent on staff for all ADLs, reported receiving cold and unappetizing food, missing items on her meal tray, and not receiving her preferred or required foods, such as oatmeal and caffeine-free beverages. She also reported receiving food with egg shells and experiencing significant delays in meal delivery, sometimes receiving meals hours late. Review of her care plans indicated she had specific dietary needs and preferences, which were not consistently honored by the facility. Another resident, who is thin and has missing teeth, reported that his meals were usually cold and tasteless, and he did not regularly receive fresh water, prompting him to keep bottled water at his bedside. Observations confirmed that his meal trays were cold and flavorless, and that he relied on bottled water due to inconsistent water delivery. During a Resident Council meeting, multiple residents unanimously expressed dissatisfaction with the food, citing issues such as poor taste, lack of variety, untimely meal delivery, unfulfilled menu preferences, and staff not respecting resident choices. These findings were corroborated by interviews with staff and direct observation of meal service.
Failure to Assess, Monitor, and Treat Surgical Wounds
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and intervention for wounds in three residents with recent amputations or surgical wounds. One resident was admitted with a right below the knee amputation (RBKA) and had no documented assessment or monitoring of the surgical site for 14 days after admission, despite hospital discharge instructions requiring daily inspection. The initial skin assessment did not mention the surgical wound, and subsequent assessments lacked details such as measurements, presence of staples or sutures, and peri-wound condition. There were no physician orders or care plan interventions addressing wound monitoring until two weeks post-admission, by which time the wound had dehisced and become infected, ultimately requiring further surgery. Another resident with a right above the knee amputation (AKA) did not have the surgical site assessed or monitored until three days after admission, and wound monitoring orders were not initiated until the fourth day. The admission skin assessment failed to mention the surgical site, and the care plan did not include specific interventions from the hospital discharge instructions, such as the use of a stump shrinker or showering guidelines. The resident reported that nurses checked the incision every other day, but documentation and orders did not reflect consistent monitoring from admission. A third resident with a left great toe amputation had an open wound that was not consistently assessed or treated according to physician orders. The skin assessment was completed four days after admission, and there was no order for wound dressing or treatment for the left great toe, despite wound care being observed and the resident expressing concern about inconsistent dressing changes. Documentation showed only weekly measurements by the wound nurse, and the care plan lacked specific interventions for the wound. Interviews with staff confirmed that wound assessment and monitoring were not routinely performed as required, and there was confusion regarding wound care orders.
Failure to Assess and Monitor PEG Tube Site and Timely Obtain Admission Weight
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube did not receive proper assessment and monitoring of the tube insertion site. During an observation, the resident was found with a reddened, raised area at the PEG site, which had gone unnoticed by nursing staff. The family reported that they had placed a dressing on the site themselves after noticing the area looked sore, and expressed concerns that nurses were not checking the site. The dressing was undated, and the resident indicated pain when the area was examined. Record review revealed that there were no physician orders for PEG site care upon admission, and no documentation of assessments or care of the PEG site in the resident's medical record. The facility's policy required daily checks and documentation of the enteral retention device and surrounding skin, but this was not followed. Additionally, the resident's admission weight was not obtained until five days after admission, despite policy requiring weights to be taken upon admission. The registered dietician and DON confirmed the delay in obtaining the weight and the lack of documentation for PEG site care. Further review showed that enteral nutrition orders were not in place until 24 hours after admission, and the resident received a different enteral formula than what was indicated on the hospital discharge summary until the correct product arrived. The DON acknowledged that the nurse failed to enter the tube feeding order on the day of admission and that documentation of PEG site assessments was missing. The facility's documentation practices did not capture the required ongoing assessment of the PEG site, and the initial nursing admission assessment did not include a skin assessment of the PEG insertion site.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed and Late Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for one resident, resulting in late and missed medication doses. The resident, who was admitted with diagnoses including aphasia following a stroke, right-sided hemiplegia, and gastrostomy status, required extensive assistance with activities of daily living but had intact cognition. Record reviews revealed multiple instances where medications were either documented as not given, left blank, or marked with a '9' on the medication administration record. Specific medications affected included atorvastatin, amantadine, famotidine, metoprolol, and heparin, with several doses either missed or not properly documented as administered. Interviews with the DON revealed that medication orders not submitted before a certain time would not be included in the next delivery, and the contracted pharmacy did not provide emergency drops for new admissions. The DON also stated that medications should be available in the backup supply, but was unable to provide a backup medication list when requested. Additionally, the DON indicated that the facility did not obtain medications from local pharmacies while waiting for deliveries from the contracted pharmacy. The pharmacy contract reviewed by surveyors required 24-hour emergency delivery for new or changed prescriptions, but this was not consistently followed, leading to the deficiency.
Failure to Document Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to properly assess and monitor a resident with pressure ulcers upon admission, leading to a deficiency in documenting these ulcers. The resident, a 56-year-old female with multiple health conditions including necrotizing fasciitis, end-stage renal disease, and bilateral above-knee amputations, was admitted with pressure ulcers that were not identified by the facility staff. Despite a progress note from the hospital indicating the presence of pressure ulcers on the coccyx and right ischium, the facility's initial skin assessment did not document these conditions. Further review revealed discrepancies in the facility's documentation and assessment of the resident's skin condition. The Unit Manager noted only a bruise and self-inflicted scratches during the initial assessment, missing the pressure ulcers that were later identified by hospital staff when the resident was sent to the ER. The facility's policy on wound prevention emphasizes the need for evidence-based interventions for residents at risk of pressure injuries, but this was not adequately followed in this case, resulting in a failure to document and address the resident's pressure ulcers upon admission.
Failure to Provide Timely Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, resulting in the resident being discharged to the emergency room with hallucinations and confusion. The resident, a 56-year-old female with end-stage renal disease and other significant health issues, was admitted to the facility with orders to receive hemodialysis three times a week. However, upon admission, the facility encountered difficulties arranging dialysis appointments due to the resident's previous non-attendance at the dialysis center, leading to a lack of available chair time. Despite attempts to coordinate dialysis, the facility did not succeed in securing treatment for the resident during her stay from September 12 to September 17. Interviews with facility staff revealed a lack of follow-up and monitoring, as the resident did not receive any dialysis treatments during this period. The Director of Nursing and other staff members acknowledged the oversight, noting that the resident's cognitive state did not initially appear to change, which contributed to the delay in sending her to the emergency room. The resident's condition deteriorated, leading to hallucinations and confusion, prompting the facility to eventually send her to the emergency room on September 17. The emergency room visit was necessitated by the resident not having received dialysis for five days, as confirmed by the nephrologist. The facility's policy required ongoing monitoring and medical management if dialysis was postponed, but this was not adequately implemented, as evidenced by the lack of weight monitoring and lab work to assess kidney function during the resident's stay.
Failure to Maintain Resident Safety Leads to Suicide Attempts
Penalty
Summary
The facility failed to maintain the safety of a resident who had a history of mental health issues, resulting in two suicide attempts by strangulation. The resident, diagnosed with Alcoholic Cirrhosis of the Liver, Paranoid Personality Disorder, and Alcohol-induced persisting Dementia, was admitted to the facility and required close supervision due to his mental health condition. Despite this, the facility did not provide adequate supervision, as evidenced by the absence of a designated 1:1 sitter on certain shifts, which contributed to the resident's ability to attempt suicide twice. The first suicide attempt occurred when the resident was found with strings tied tightly around his neck, which had to be cut off by a nurse. Despite being sent to the emergency room for evaluation, the resident returned to the facility without new orders and was placed on 1:1 supervision. However, the facility failed to ensure continuous 1:1 supervision, as there was no specified sitter for the resident on the 2nd and 3rd shifts on a subsequent day. This lack of supervision allowed the resident to attempt suicide again by wrapping a phone charger cord around his neck. Interviews with staff revealed confusion and miscommunication regarding the assignment of 1:1 sitters, and a lack of a clear policy to address suicidality and subsequent procedures. The facility's failure to implement and maintain appropriate interventions and supervision for the resident's safety led to the citation of past non-compliance.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent the deterioration of wounds for three residents, leading to significant health issues. Resident #74, who was admitted with a pressure ulcer on the coccyx, did not receive the prescribed wound care treatment consistently. The treatment orders were not followed, and there was confusion between two different wound care treatments. The wound care practitioner had ordered Triad cream, but the facility also had an order for Allevyn, which was not completed on several occasions. This inconsistency and lack of proper wound care led to the worsening of Resident #74's wound, resulting in infection and sepsis. Resident #290 had a dressing on the right foot that was not dated or initialed, which is against nursing standards of practice. The dressing was observed to be dried onto the wound, indicating that it was not changed as required. This oversight in wound care documentation and management could potentially lead to further complications for the resident. Resident #292 had bilateral foot dressings that were not dated or initialed, and the resident was not wearing heel protectant boots as ordered. The care plan indicated the need to elevate heels, but the specific order for heel protectant boots was not included in the care plan or Kardex. This lack of adherence to physician orders and care plan documentation contributed to inadequate wound care management for Resident #292.
Inadequate Supervision and Documentation Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and post-fall assessments for two residents, leading to significant injuries. Resident #84, who was an active exit seeker and oriented only to self, attempted to leave the building unauthorized. During this attempt, he was startled by a staff member, tripped, and sustained a head injury that required emergency medical treatment, including stitches. Despite the facility's policy requiring neurological assessments post-fall, no such evaluations were documented for Resident #84 following his return from the hospital. Resident #17, who had a history of dementia and severely impaired cognition, sustained fractures to the third and fourth metacarpals of his right hand after a fall. The incident occurred while Resident #17 was visiting another resident in her room, contrary to the facility's guidance to visit in more public areas. The Director of Nursing confirmed that there were no witness statements from staff regarding the incident, and the care plan for Resident #17 did not include increased supervision or measures to prevent him from entering other residents' rooms. The facility's failure to adhere to its fall management policy and ensure proper documentation and supervision contributed to the injuries sustained by both residents. The lack of a comprehensive post-fall assessment for Resident #84 and the absence of preventive measures in Resident #17's care plan highlight deficiencies in the facility's management of resident safety and accident prevention.
Inaccurate Infection Control Program and Outdated Policies
Penalty
Summary
The facility failed to maintain an accurate infection control program, as evidenced by inconsistencies in tracking infections within the resident population. In January 2024, there were discrepancies between the number of infections highlighted on the mapping, the line listing, and the summary, with some infections not meeting antibiotic criteria yet being treated with antibiotics. Similar inconsistencies were noted in February, March, and April 2024, with infections being placed on antibiotics without meeting criteria and discrepancies in infection counts across different records. Additionally, the facility's infection control policies were outdated, with some not having been revised since 2016 or 2018, and there was a lack of education provided to staff regarding infection control procedures. Interviews with the infection preventionist and the Director of Nursing (DON) revealed a lack of awareness and action regarding the increase in infections, particularly urinary tract infections (UTIs). The infection preventionist, who had recently taken over the role, was not aware of the need for education in response to the infection increase. The DON confirmed that the infection control policies were not current and that there were no audits or education on antibiotic stewardship. The mapping, line listing, and summaries did not match due to the absence of a consistent infection preventionist, as the previous one had been incapacitated, leading to a piecemeal approach to infection control management by the DON and regional consultant nurses.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, leading to a deficiency in the care of activities of daily living (ADL). Resident #8, who has a self-care deficit due to morbid obesity and a below-the-knee amputation, did not receive scheduled showers on two occasions, with no documentation explaining the missed showers. Similarly, Resident #51, who requires assistance due to physical limitations and cerebral palsy, reported missing a scheduled shower, attributing it to staff shortages. The task list and progress notes for Resident #51 also lacked documentation for missed showers on two scheduled days. Resident #17 and Resident #20 both refused showers on multiple occasions, but there was no documentation of alternative bathing options being offered. Resident #17's care plan required staff assistance for showers twice a week, yet there was no record of why the resident refused or if alternatives were provided. Resident #20 also refused showers on several days, and the facility did not offer a bed bath or alternative day, as indicated by the shower sheet documentation. The facility's ADL policy states that care and services should be provided to prevent deterioration in residents' abilities, but the lack of adherence to scheduled bathing routines indicates a failure to meet this standard.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed for a resident, resulting in an 8% error rate. The errors were identified during a medication administration observation involving a Licensed Practical Nurse (LPN) and a resident. The LPN noted that the medications pantoprazole (Protonix) 40mg and Entresto 24-26mg were not available in the facility's medication dispensing machine, despite having ordered them the previous day. The LPN mentioned that the pharmacy typically delivers medications at night and confirmed that the order had been placed, but the medications were still unavailable. The resident's Medication Administration Record (MAR) indicated that pantoprazole was to be administered once daily for acid reflux, and Entresto was to be given twice daily for heart failure, both starting from earlier in the month. The MAR entries for the date in question directed to see progress notes, which confirmed the unavailability of both medications. This lack of medication availability and administration as prescribed contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, leading to several deficiencies. During an observation, a medication cart was found unlocked and unattended in the hallway, with a half-eaten sandwich and a bottle of water on top. The drawers of the cart were accessible, except for the narcotic drawer, and contained loose medications. A Licensed Practical Nurse (LPN) admitted to leaving the cart to inform management of the state surveyor's presence. Additionally, another LPN identified loose tablets in a different medication cart, and there were no antibacterial wipes available for cleaning the glucometer, which was placed back into the cart after use. Further observations revealed expired and undated medications in the facility. In the East med room, a bottle of Tuberculin was found opened without a date, and a resident's latanoprost eye drops were undated and half full. On the North Hall medication cart, several medications, including Timolol and Brimonidine eye drops, and insulin vials, were either expired or lacked open and use-by dates. The facility's policies on medication storage and administration were not adhered to, as medications were not properly labeled or stored, increasing the risk of decreased efficacy and potential drug diversion.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks for all residents consuming food from the kitchen. Observations revealed that the kitchen staff did not adhere to proper hygiene practices, such as wearing hair and beard nets, as required by the facility's policies. Specifically, a dietary aide refused to wear the necessary hair and beard nets and was subsequently sent home. Additionally, the kitchen floors were observed to have food droppings and debris, and the griddle had burnt-on food residue from previous meals. The dishwasher room was also noted to have debris on the floors and overflowing trash cans. The facility's food storage practices were found to be inadequate, with improperly labeled and stored food items in the coolers. An opened box of apple juice without an open date and a container of tea past its expiration date were found in the refrigerator. The kitchen's cleaning schedule was not consistently followed, as evidenced by the presence of unswept floors and dirty countertops, despite staff signing off on completed cleaning tasks. The kitchen manager acknowledged that the cleaning procedures were not being followed by the newer, younger staff, and that there was a significant buildup of lime on the dishwasher surfaces. Further observations highlighted improper glove use by kitchen staff during meal preparation and service. A cook was seen using the same pair of gloves for multiple tasks without washing hands in between, including handling food and opening storage areas. Additionally, structural issues were noted, such as an unfinished kitchen doorway with exposed drywall and metal, and an open drain under the sink without a cover. These deficiencies indicate a lack of adherence to professional standards for food safety and sanitation, posing a risk to the health and safety of the residents.
Deficiency in Vaccination Program
Penalty
Summary
The facility failed to maintain an effective vaccination program for four residents, as identified during a survey. Resident #59 had a signed consent for a pneumococcal vaccination, but the vaccine was never administered. Additionally, the consent form indicating refusal of the Pneumovax-23 vaccine lacked a date. Resident #72's records showed no consent or administration of influenza and pneumococcal vaccines. Resident #74 had consents signed for pneumococcal, influenza, and COVID-19 vaccinations, but none were administered. Resident #86's records lacked both immunization consents and any administered vaccines. Interviews with facility staff revealed gaps in the vaccination process. The Director of Nursing (DON) acknowledged that the infection preventionist did not have access to the State Agency Vaccination Database, which hindered the vaccination process. The DON admitted that immunizations should be offered upon admission and consents obtained at that time. An LPN was unable to explain why Resident #74 did not receive vaccinations despite signed consents. The facility's policies on influenza and pneumococcal vaccines were outdated, lacking current CDC recommendations, which contributed to the deficiencies.
Deficient Equipment Maintenance in Resident Rooms
Penalty
Summary
The facility failed to maintain essential resident equipment in safe operating condition, affecting multiple residents. In one instance, a resident in room 42A reported nearly falling due to a bed that did not lock properly, which had been an ongoing issue for weeks. The resident had previously fallen and bruised her shoulder due to the bed's instability. Despite the resident and her family notifying the staff, the issue remained unresolved until the surveyor's intervention. Additionally, another resident in the same room experienced frustration as their bed would not adjust up or down due to a malfunctioning remote control, which was not addressed until the surveyor's report. In room 63A, a resident's wheelchair was found to have loose wheels, which the resident had reported but remained unfixed until the surveyor's involvement. The resident expressed distress over the situation, and the staff was unaware of the issue until it was brought to their attention by the surveyor. Similarly, in room 3B, an overhead light fixture was cracked, posing a potential hazard, and had been in this condition for over a month without being addressed, despite the resident's report to the staff. The facility's maintenance staff and administration were unaware of these equipment issues, as there was no record of maintenance requests for the affected rooms. The Maintenance Director, who had been in the position for only two weeks, confirmed that they were not informed of these concerns until the surveyor's report. The Director of Nursing was also unaware of the equipment issues contributing to a resident's fall, as the fall report did not mention any bed-related problems. The Nursing Home Administrator could not provide an equipment policy, indicating a lack of systematic checks and communication regarding equipment maintenance.
Deficiencies in Resident Dignity and Call Light Response
Penalty
Summary
The facility failed to ensure resident rights pertaining to dignified care for several residents, resulting in multiple deficiencies. One resident, who was cognitively intact, reported being left wet due to untimely call light responses and the call light being out of reach. The resident expressed frustration over the situation, which was confirmed by a Licensed Practical Nurse who observed the call light was not properly placed. Another resident, also cognitively intact, reported waiting two to three hours for call light responses, which was particularly distressing due to their dependency on staff for mobility and personal care needs. Additional residents reported similar issues with call light response times, leading to prolonged periods of incontinence and frustration. One resident described waiting for hours to be assisted with a bedpan, while another reported that staff would turn off the call light at night and not return. The facility's failure to ensure timely call light responses was further highlighted during a confidential group meeting, where multiple residents shared experiences of extended wait times and feelings of neglect. The facility also failed to maintain privacy and dignity for a resident with severe cognitive impairment. This resident was observed exposed in their room with the door open, while staff attended to a roommate behind a curtain. The lack of privacy was not addressed until several minutes later when a staff member covered the resident. Additionally, a resident was observed being denied timely assistance for a change before a meal, with a CNA expressing frustration and refusing to assist, citing workload as a reason. These incidents collectively demonstrate a significant lapse in maintaining resident dignity and timely care.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for a resident, resulting in discrepancies in the documentation of controlled substances. During an inspection of the North Hall medication cart, a discrepancy was found in the controlled substance log for a resident's Tramadol 50 MG. The facility was dispensed 30 pills, but the count was inaccurate, with one pill unaccounted for. The controlled substance form showed inconsistencies in the number of pills remaining, particularly on 5/17/2024, when the count decreased by two pills instead of one. This discrepancy was not caught during the routine narcotic count conducted at the beginning and end of each shift. Further review of the Medication Administration Record (MAR) from 5/15/2024 to 5/21/2024 revealed that Tramadol was documented as administered only three times, while the narcotic sheet indicated it was given eight times. This inconsistency suggests that facility nurses were not accurately documenting medication administration. The Director of Nursing (DON) confirmed that the MAR and narcotic sheet should match, but the investigation revealed that the missing Tramadol pill was still unaccounted for, and there was no documentation of it being wasted. The facility's policies on controlled substances and medication administration require accurate documentation and reconciliation of medications at each shift change. However, the failure to adhere to these policies led to the misappropriation of a resident's medication and inaccuracies in the controlled substance log. The nurse involved in the discrepancy was identified and suspended pending further investigation, highlighting the need for improved oversight and adherence to established procedures.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the State Agency for a resident, resulting in a potential for undetected abuse or neglect. The incident involved a resident who was assisted to the Central unit by another nurse after visiting another resident and experiencing a fall. The resident was found sitting in a wheelchair with an ice-wrapped right hand, and the tip of the right finger was bent upward. The resident was transferred to the emergency room, and upon return to the facility, X-ray results indicated fractures to the third and fourth metacarpals, with a cast noted on the right hand up to the arm. An interview with the Director of Nursing confirmed that the injury was not reported to the State Agency, as required by the facility's Abuse Prevention Program, which mandates immediate notification of such incidents to the appropriate authorities.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation for an injury of unknown origin involving a resident with dementia and severely impaired cognition. The resident was admitted with diagnoses including dementia with other behavioral disturbances and had a BIMS score indicating severe cognitive impairment. On a specific date, the resident was found with an injury to the right hand after visiting another resident. The injury was severe enough to require an emergency room visit, where fractures to the third and fourth metacarpals were diagnosed, and a cast was applied. The Director of Nursing confirmed that the investigation into the incident did not include witness statements from staff, despite the presence of staff who could have provided information. The facility's policies on abuse prevention and investigation require comprehensive steps, including interviews with involved staff and witnesses, which were not followed. This oversight resulted in a deficient practice with the potential for undetected abuse or neglect and unmet care needs for the resident.
Deficient PICC Line Management in LTC Facility
Penalty
Summary
The facility failed to provide care and services according to its policy and standards of clinical practice for two residents with Peripheral Inserted Central Catheter (PICC) lines. For Resident #290, the PICC line dressing was observed to be non-occlusive and dated 5/8, despite the resident being admitted on 5/10. The dressing had not been changed during the resident's stay, contrary to the facility's policy of weekly dressing changes. Additionally, there were no initial measurements of the PICC line upon admission, and the orders for PICC line monitoring and dressing changes were delayed by several days. Similarly, Resident #292's PICC line dressing was also non-occlusive, and flex tape was used in an attempt to secure it. The resident's medical records lacked documentation of initial measurements upon admission, and the dressing was not changed despite its condition. The facility's policy requires weekly dressing changes and initial measurements of arm circumference and catheter length upon admission, which were not adhered to in these cases. The discrepancies in documentation and untimely monitoring and dressing change orders were acknowledged by the facility's management.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. Resident #60 was administered Paliperidone, an antipsychotic medication, for eight weeks without proper consent from her court-appointed guardian. Although verbal consent was reportedly obtained, there was no documentation to support this claim, and the consent form was not completed until eight weeks after the medication was ordered. The facility's policy on psychotropic management did not address the requirement for informed consents, contributing to the oversight. Resident #84 was administered multiple psychotropic medications, including two antipsychotics, an antidepressant, and Alzheimer's medication, without any signed consents. The resident was admitted to the facility from a hospital and was noted to be alert and oriented to self only. Despite the facility's efforts to work with the resident's daughter to obtain guardianship, no consents were documented for the medications administered. This lack of documentation and consent raises concerns about the appropriateness of the drug regimen and the potential for adverse side effects.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer and document medications per professional standards of practice for two residents, resulting in a discrepancy with narcotic medication and erroneous medication documentation. For Resident #58, a discrepancy was found in the controlled substance log for Tramadol, where one pill was unaccounted for. The log indicated that two pills were deducted on a specific date, although only one was administered. This discrepancy was confirmed by a count of the remaining pills, and the Director of Nursing (DON) acknowledged that the medication was still unaccounted for after an investigation. For Resident #293, the issue involved the attempted administration of Melatonin without a proper order. The resident refused the medication, and it was later discovered that the nurse involved had backdated entries in the medical record to justify the administration. The Medication Administration Record (MAR) showed discrepancies in the timing of the medication order and administration, and the nurse's documentation did not align with the actual events. The DON confirmed that the nurse had attempted to backdate the MAR entry and had documented the medication as given on an incorrect date. The facility's internal investigation revealed that the nurse involved, Nurse V, had a history of medication administration violations, including gross negligence and administering medication without proper orders. Despite being deemed competent in medication administration, Nurse V continued to demonstrate a lack of adherence to professional standards. The facility's policies on administering medications and documentation in medical records were not followed, leading to inaccurate and untimely documentation of medication administration.
Failure to Complete Yearly PASSAR and Level II Evaluations
Penalty
Summary
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. Resident #602, admitted with diagnoses including Depression and Anxiety, had a comprehensive Level II evaluation due by March 11, 2022, but the most recent documentation was from May 17, 2023, without any other correspondence for 2023. Resident #604, with diagnoses including Dementia and Depression, had a PASSAR dated March 15, 2021, but no corresponding SAR (78) document. The Social Work Director (SWD) and Director of Nursing (DON) acknowledged the lack of up-to-date documentation and mentioned issues with access to the OBRA system as a contributing factor. Resident #603, with diagnoses including Major Depressive Disorder and Schizophrenia, had a PASSAR/Level II assessment dated October 28, 2022, but no documentation for 2023 and 2024. The SWD confirmed the absence of up-to-date assessments for this resident as well. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
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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.
Trusted data from CMS and state health departments
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