Majestic Care Of Livonia
Inspection history, citations, penalties and survey trends for this long-term care facility in Livonia, Michigan.
- Location
- 28550 Five Mile Road, Livonia, Michigan 48154
- CMS Provider Number
- 235057
- Inspections on file
- 38
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Majestic Care Of Livonia during CMS and state inspections, most recent first.
A resident with Down Syndrome, major depressive disorder, moderate intellectual disabilities, severely impaired cognition, and a documented history of refusing showers/ADLs was subjected to a shower despite clearly stating they did not want one. The assigned CNA and another CNA reported hearing the resident repeatedly refuse the shower while an assisting CNA told the resident they were going to take the shower. The resident was observed with wet clothes and soap on their face, and an LPN observed the resident in the shower room with clothes still on, a soiled shirt on the floor, and the resident at the sink with pants down. These events occurred despite a facility policy affirming residents’ rights to self-determination and to refuse care.
Multiple residents with significant mobility, cognitive, and sensory impairments did not receive timely assistance with ADLs or prompt responses to call lights. One resident with paralysis and heart disease reported call lights going unanswered for over thirty minutes and showed video of empty hallways, leading them to get out of bed without needed help. Another resident with paraplegia reported delayed incontinence and wound care and was observed waiting at their doorway and then at the nurse station for assistance to be changed. A resident with quadriplegia and severe cognitive impairment was repeatedly observed lying on their back in bed or in a recliner without effective use of positioning devices to offload pressure. A legally blind resident who required help with ambulation and dressing waited extended periods for staff to escort them from the dining room and to the bathroom, with their call light ultimately answered by the DON rather than unit staff. Another cognitively intact resident needing ADL assistance reported call lights sometimes taking over an hour to be answered and was observed having their call light turned off by staff before the requested brief change was provided, contrary to facility policy requiring timely call light response.
A resident's prescribed narcotic pain medication was misappropriated when two sleeves of Norco were delivered but only one was accounted for, with the discrepancy occurring while the medication was under the care of an LPN. The issue was discovered after a pharmacy refill request was denied, and investigation revealed a hand-written label on the count sheet and missing medication. The resident received pain medication from the emergency backup supply, and no other discrepancies were found in other residents' narcotics.
A resident with severe cognitive impairment had multiple incidents of inappropriate contact with another resident. The facility failed to update the care plan with new interventions after the initial incident, despite further occurrences. Staff confirmed monitoring was initially increased but later reduced, and the facility's policy did not address care plan revisions for significant events.
The facility did not ensure RN coverage for at least eight consecutive hours on a weekend day, as required. A review of the nurses' schedule showed no RN was on duty on a specific date due to the scheduled RN's illness. This was confirmed by the scheduler staff and the Nursing Home Administrator.
An inspection revealed deficiencies in food storage and pest control, including undated food items in coolers, swarms of gnats near the dish machine, and standing water issues. The Dietary Manager could not explain these issues, which violate FDA Food Code requirements for food safety and pest control.
A resident with severely impaired cognition and requiring substantial assistance was referred to with potentially derogatory language in a care order. An LPN used the term 'feeder' to describe meal assistance, which was later confirmed as inappropriate by both the LPN and the DON. The facility's policy on dignity was not upheld, as it emphasizes treating residents with respect and dignity.
A resident with a history of falls and a diagnosis of hemiplegia was found with a bruise from a fall, yet their care plan had not been updated since May 2023. The facility's DON admitted to not completing necessary steps post-fall, and the facility lacked a specific policy for care plan revisions after falls, despite having a Fall Prevention policy requiring such updates.
A resident with Alzheimer's disease and severe cognitive impairment was observed multiple times without the necessary hand splints, which were prescribed to be worn at all times except for hygiene. Despite physician orders and facility policy emphasizing the importance of consistent use, the resident was seen with contracted hands and difficulty eating, indicating a failure in care by the facility.
The facility failed to date opened biologicals in three medication carts, including insulin vials, glucose test strips, and eye droppers. Observations revealed undated items in the A, D, and C medication carts. The DON confirmed the requirement to date these items, aligning with the facility's policy and manufacturer guidelines.
The facility failed to provide food that was palatable and presentable for three residents, leading to dissatisfaction with taste and variety. One resident, a newer admission for rehabilitation, expressed concern over the food's taste and variety, while another criticized the eggs and bread quality. A third resident noted issues with the grits' texture and the presentation of meals. The facility's dietary staff acknowledged these complaints, and the Nutritional Services policy lacked guidance on food palatability and presentation.
A resident with a documented seafood allergy was mistakenly served shrimp, leading to an allergic reaction. The resident, believing the dish was chicken, experienced a tingling sensation in their mouth and tongue after consuming the shrimp. A CNA notified an LPN, who administered Benadryl. The incident was not documented in the resident's medical records, and the dietary management confirmed the allergy was clearly marked on the meal ticket. The facility's policy requires allergies to be noted on tray cards, which was not followed.
A facility failed to implement proper transmission-based precautions for a resident with an infection, as staff did not consistently use PPE or perform hand hygiene. Additionally, the facility did not ensure timely dressing changes for a resident's PICC line, as required by physician orders. These deficiencies highlight lapses in adherence to infection prevention and vascular access management policies.
The facility failed to provide adequate hygiene care and meal assistance to two residents. One resident, who required assistance with bathing, had not received a shower in over a month despite being scheduled for twice-weekly showers. Another resident with severe cognitive impairment and a need for 1:1 assist feeding was observed with uneaten meals and nutritional drinks left untouched. The facility did not adhere to its policy on activities of daily living, resulting in deficiencies in both hygiene care and meal assistance.
A facility failed to apply lymphedema wraps for a resident with heart failure and swelling, despite a physician's order. The resident reported increased swelling, and observations confirmed the absence of wraps. Additionally, another resident with severe cognitive impairment and a stage 2 wound was not repositioned regularly, lacking a necessary positioning wedge. Staff confirmed the resident's need for assistance, and the DON acknowledged the requirement for regular repositioning.
The facility failed to provide adequate tube feeding and hydration for a resident, as their tube feeding was not connected despite physician orders. Another resident with severe cognitive impairment did not receive meal assistance or nutritional supplements as prescribed, leading to weight loss. The facility's policies on enteral feeding and nutrition management were not followed, resulting in these deficiencies.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to a deficiency. The resident was issued an involuntary discharge notice without prior awareness, triggering a traumatic reaction. The care plan lacked interventions to address PTSD triggers, and there was no documentation of a PTSD assessment. Facility staff were unaware of the resident's PTSD diagnosis until after the incident, highlighting deficiencies in trauma-informed care practices.
A resident with paraplegia and a stage three pressure ulcer was not repositioned as required, leading to a deficiency in skin care management. Despite the care plan's directive for routine repositioning and assistance, the resident was observed lying on their back for extended periods without pressure-relieving devices. The facility's policy emphasizes pressure redistribution, but the expected repositioning every two hours was not adhered to.
A resident with Alzheimer's and mobility issues was left in a wet incontinence pad and bedding for several hours, despite clean supplies being available. The CNA confirmed the resident was only changed once in the morning, contrary to the facility's policy of checking and changing every two hours. The DON acknowledged this was unacceptable.
A facility failed to follow hospital discharge instructions for a resident with Multiple Myeloma, resulting in missed follow-up appointments with specialists. The resident or their daughter canceled an initial oncology appointment, and subsequent appointments were not documented as attended. Staff changes and transportation concerns contributed to the deficiency.
A resident with multiple health conditions was not allowed to return to the facility after hospitalization due to aggressive behavior and non-compliance with care. Despite being medically and psychiatrically cleared, the facility cited a lack of staff to manage the resident's needs and safety concerns for staff as reasons for refusal. The facility's actions were based on their Transfer and Discharge policy, which allows for discharge if a resident's needs cannot be met or if safety is endangered.
A resident with impaired cognition and a history of schizoaffective disorder eloped from the facility without injury. Staff interviews revealed that an alarm sounded but was turned off by an employee, and a food delivery was placed near the alarming door. The facility's elopement policy was not effectively implemented, leading to the resident's unsupervised exit.
A resident with impaired cognition and multiple diagnoses developed a pressure ulcer that worsened due to the facility's failure to implement timely wound care treatments. Despite the initial identification of a wound on the sacrum, a treatment order was delayed for 19 days, leading to the progression of the wound to a stage 3 ulcer. The DON acknowledged the lapse in following the facility's policy for wound prevention and care.
The facility failed to honor residents' rights to self-determination regarding Leave of Absences (LOAs) by implementing restrictive guidelines. These included specific times for LOAs, weather-related restrictions, and the requirement for residents to be accompanied by a community member. The guidelines were established after discussions with the medical director, law enforcement, and community members due to concerns about resident behaviors in the community. The restrictions contradicted the facility's Therapeutic Leave policy, which allowed residents to leave for non-medical visits in accordance with federal and state guidelines.
The facility failed to consistently assist the Resident Council in holding monthly meetings, as identified during a mock survey. The NHA acknowledged the deficiency, presenting incomplete or undated meeting notes. The turnover of three Activity Directors in the past year contributed to disorganized records, violating the policy that mandates monthly meetings with resident participation.
The facility did not have a qualified professional directing the activities program, affecting all 95 residents. The NHA noted a new Activities Director was hired recently, but there was no one in the role when he started. The current Activities Director began in June, and an Activities Aide confirmed the absence of a director since April. The DON recalled the last director was in March. The Activities Policy lacked details on qualifications.
A resident diagnosed with Schizoaffective Disorder-Bipolar Type, Anxiety Disorder, Violent Behavior, and Vascular Dementia eloped from the facility despite wearing a Wanderguard ankle bracelet. The resident's care plan included interventions for wandering and exit-seeking behaviors. However, the resident managed to leave undetected, and staff became aware of the elopement approximately eight hours later. Staff interviews revealed inconsistencies in recollections of door alarms, and surveillance footage showed the resident outside the facility for several hours before being noticed missing.
Failure to Honor Resident’s Refusal of Shower and Right to Dignified Care
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to refuse care and to be treated with dignity when staff proceeded with a shower despite the resident’s verbal refusals. The resident, who had Down Syndrome, major depressive disorder, moderate intellectual disabilities, a BIMS score of 3/15 indicating severely impaired cognition, and a documented history of refusing showers/ADLs, was the subject of a complaint alleging they were forced to shower. According to the facility’s investigation, the CNA assigned to the resident requested assistance from another CNA. The assigned CNA reported hearing the resident say, "I don't want to take a shower; I don't want to take a shower," and heard the assisting CNA respond, "you're going to take this shower." Another CNA, who was nearby, also reported hearing the resident repeatedly say "No shower" and a CNA telling the resident, "you are going to take a shower." The investigation further documented that the assisting CNA stated the shower was already running and spraying water on the resident when they entered the shower room, and that the resident left the shower room and walked to their room with wet clothes on before staff could assist. The assigned CNA reported returning to the shower room and observing the resident wearing wet clothes with soap on their face. An LPN reported being told by the assigned CNA that the assisting CNA had started wetting the resident while the resident’s clothes were still on, and the LPN observed the resident in the shower room with clothes still on, a soiled shirt on the floor, and the resident at the sink with their pants down. The facility’s resident rights policy states that residents have the right to a dignified existence, self-determination, and to make choices about schedules and care, including the right to refuse showers or care.
Failure to Provide Timely ADL Assistance and Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs) and to respond promptly and appropriately to call lights for multiple residents. One resident with right-sided paralysis, stroke, and heart disease, who required partial to moderate assistance for mobility, reported that on afternoon and night shifts their call light was sometimes left unanswered for more than thirty minutes. The resident and a family member stated there was a camera in the room and played a video showing empty hallways during late afternoon and nighttime hours. When the call light was not answered, the resident reported having to get out of bed independently despite documented needs for assistance. Another resident with paraplegia and schizophrenia, who was care planned as requiring assistance with ADLs and having episodes of incontinence, reported not receiving timely wound care and stated that dressings on their feet had not been changed in two weeks. This resident also reported needing assistance to change their brief due to urinary incontinence. On one observation day, the resident was seen in a powered wheelchair at their doorway stating they were waiting for assistance, while three staff were in the area and one walked by without acknowledging them. After waiting, the resident moved to the nurse’s station to request help and later complained of having waited thirty minutes for assistance to be changed. The DON acknowledged awareness of this resident’s care needs and behavior history, including reports that the resident was not always truthful about care requests. A resident with quadriplegia, bilateral hand contractures, dementia, and severe cognitive impairment, who was dependent on staff for all ADLs including bed mobility, transfers, and personal hygiene, was repeatedly observed lying on their back in bed or in a recliner for extended periods without effective use of positioning devices to offload pressure. Over multiple observations across several days, the resident remained on their back in bed or in a medical recliner, often with wedges or pillows present but not positioned under the resident in a way that would offload pressure from the back and buttocks. The resident was also observed with apparent foot drop and heels resting directly on surfaces without protective devices in place. Another resident with legal blindness, adjustment disorder, and a history of falls, who required assistance with ADLs and minimal assistance for most tasks, reported needing help to get dressed and to walk with a walker to the dining room but was later observed eating lunch in their room instead. On a subsequent day, this resident was seen seated at a dining room table before lunch and remained there for an extended period, asking if their aide was available to walk them back to their room while no staff were visible in the halls or at the nurse station. The resident later reported that restorative staff, who walk with them a few times a week, had assisted them back to their room. The same resident activated their call light to request help to the bathroom; several minutes later, the DON happened to walk by, answered the call light, and assisted the resident, with no other staff responding. The resident also reported having requested a t-shirt from night staff to wear under their hospital gown and not receiving it. A further resident, cognitively intact and requiring staff assistance for ADLs following a right lower leg bimalleolar ankle fracture, reported that staff sometimes took over an hour to answer call lights. During one observation, this resident’s call light was on for several minutes before staff arrived and the resident requested a brief change. Staff then went to the nurse’s station, returned to the room, and turned off the call light despite the resident asking to keep it on because staff often did not return once the light was turned off. The resident explained that staff frequently turned off the call light without providing the requested care. Facility policies reviewed by surveyors stated that comprehensive care plans must be implemented to meet residents’ medical, nursing, mental, and psychosocial needs, and that all staff are responsible for responding to call lights and ensuring requested services are provided in a timely manner.
Failure to Prevent Misappropriation of Controlled Substance
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's prescribed controlled substance, specifically a narcotic pain medication. The incident involved a resident with diagnoses of metabolic encephalopathy and end stage renal disease, who required staff assistance with activities of daily living and had intact cognition. The issue was discovered after a pharmacy refill request for the resident's pain medication was denied due to being too early, prompting further investigation by the Director of Nursing (DON). Upon review, it was found that two sleeves of 30 Norco 10/325 pills each had been delivered to the facility, but only one sleeve was accounted for on the narcotic count sheet. The count sheet for the missing medication had a hand-written identification label instead of the standard pharmacy-provided sticker. By cross-referencing pharmacy records, handwriting, and staff schedules, it was determined that the discrepancy occurred while the medications were under the care and control of an LPN. The resident received pain medication from the facility's emergency backup supply during this period. The facility's investigation did not uncover evidence supporting alternative explanations for the missing medication. Audits of other residents' narcotics did not reveal further discrepancies. The facility's policies require controlled substances to be stored securely and for any discrepancies in controlled medication counts to be reported and investigated immediately, but these procedures were not effectively followed in this instance, resulting in the misappropriation of the resident's medication.
Failure to Revise Care Plan After Multiple Incidents
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R702, following multiple incidents of inappropriate contact with another resident, R703. The initial incident occurred on 12/20/24 and was directly witnessed by staff, who intervened immediately. Despite this, the care plan for R702 was only updated with interventions following the first incident, and no further interventions were added after subsequent incidents on 01/01/25 and 01/20/25. R702 has a diagnosis of Dementia and Disorientation, with a BIMS score indicating severe cognitive impairment. The care plan included a focus area addressing R702's behavior, but it was not adequately revised to reflect ongoing issues. Interviews with staff, including a physical therapist and an LPN, confirmed that R702's behavior had been monitored, with checks every 30 minutes initially implemented but later lifted. The facility's policy on comprehensive care plans did not specifically address the need for revisions in response to significant events, which contributed to the oversight. The facility's administrator and DON acknowledged the deficiency, noting that interventions had been effective but were not documented in the care plan as required.
Failure to Provide RN Coverage on Weekend
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours per day on weekends, specifically on December 7, 2024. This deficiency was identified through a review of the nurses' schedule for four weeks in November and December 2024, which revealed the absence of documented RN coverage on the specified date. During an interview on December 10, 2024, the scheduler staff confirmed the lack of RN on duty on December 7, 2024. Additionally, the Nursing Home Administrator, in an email exchange, confirmed with the Director of Nursing (DON) that the scheduled RN was unable to work due to illness, resulting in no RN coverage on that day.
Food Storage and Pest Control Deficiencies
Penalty
Summary
During an inspection of the kitchen, several deficiencies were observed related to food storage and pest control. In the walk-in cooler, multiple food items, including a pan of soup, bags of chicken and ham, and packages of hot dogs and tomato sauce, were found without proper date markings. Additionally, a crate of milk was past its use-by date. In the Traulsen reach-in cooler, containers of Italian dressing, sweet and sour sauce, and BBQ sauce were also undated or past their use-by dates. The Dietary Manager was unable to provide an explanation for these issues. According to the 2017 FDA Food Code, ready-to-eat, potentially hazardous food must be clearly marked with a date to ensure it is consumed or discarded within a safe timeframe. Further inspection revealed pest control issues in the dish machine room, where swarms of gnats were observed near the soiled side of the dish machine. Standing water was found underneath the sink basin, and missing grout between floor tiles allowed water to accumulate. The Dietary Manager acknowledged that a pest control company treats the drains but did not explain the stagnant water issue. Additionally, spilled milk was found pooled at the bottom of the Motak milk cooler, and undated food items were discovered in the resident refrigerator. These conditions violate the FDA Food Code requirements for maintaining a pest-free environment and ensuring nonfood-contact surfaces are cleaned regularly.
Inappropriate Language in Resident Care Order
Penalty
Summary
The facility failed to ensure a resident was referred to with dignity, as evidenced by the use of potentially derogatory language in the resident's care order. The resident, who was admitted to the facility with severely impaired cognition and required substantial assistance for activities of daily living, had an order entered by an LPN that used the term 'feeder' to describe the assistance needed for meals. This term was deemed inappropriate by both the LPN and the Director of Nursing, who confirmed that the order should have used language such as 'assist with all meals' or 'one to one assist with all meals'. The facility's policy on dignity emphasizes treating residents with respect and dignity, which was not upheld in this instance.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update a resident's care plan to reflect fall interventions after multiple incidents. A resident, identified as R10, was observed with a bruise around their right eye, which they explained was due to falling out of bed and hitting their face on a nightstand. The resident's environment was noted to be cluttered, and they reported that no measures had been put in place to prevent future falls. The resident had a history of falls, with incidents recorded on three separate occasions due to self-transfer, yet the care plan had not been revised since May 2023. The Director of Nursing acknowledged that the necessary steps were not completed after the resident's falls. The facility lacked a specific policy for revising care plans post-fall, although their Fall Prevention policy required a review and update of the care plan following a fall. The resident's medical record indicated a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, with intact cognition and a need for assistance with daily activities. Despite these needs and the history of falls, the care plan had not been updated to address the risk factors and environmental hazards effectively.
Failure to Consistently Apply Hand Splints for Resident
Penalty
Summary
The facility failed to apply hand splints for a resident, identified as R38, who was observed multiple times without the necessary hand splints in place. R38 was seen lying in bed with contracted hands and the hand splint was observed on the nightstand rather than on the resident. This occurred on several occasions, including when R38 was in a wheelchair in the dining room, where only one hand splint was applied, and the resident was observed eating with difficulty. R38's medical record indicated a diagnosis of Alzheimer's disease with severe cognitive impairment, and physician orders specified the use of lambs wool and gel splints to be worn at all times except for hygiene purposes. Interviews with facility staff, including an LPN, the Physical Therapy Director, and the Director of Nursing, confirmed that the hand splints should be consistently applied and only removed for hygiene. The facility's policy on assistive devices emphasized the importance of proper and consistent use of such devices to maintain or improve function and dignity. Despite this policy, the facility did not ensure the consistent application of the hand splints for R38, leading to a deficiency in care.
Failure to Date Opened Biologicals in Medication Carts
Penalty
Summary
The facility failed to ensure that biologicals were dated when opened, as observed in three medication carts. On December 8, 2024, a glucose test strips container was found undated in the A medication cart with an LPN. Similarly, the D medication cart contained an open and undated vial of Lantus insulin, a vial of Humalog insulin, a container of glucose test strips, and two latanoprost eye droppers. On December 9, 2024, the C medication cart was found with an undated Humalog insulin vial, three artificial tears eye dropper vials, and a glucose test strips container. During an interview on December 10, 2024, the DON confirmed that glucose test strips and insulin vials should be dated when opened, with glucose strips being valid for thirty days post-opening. The facility's policy mandates that all medications be stored according to the manufacturer's recommendations, ensuring proper conditions and security. The prescriber information for Lantus, Humalog, and latanoprost specifies storage guidelines, including the duration for which they remain usable once opened. The failure to date these biologicals upon opening indicates a lapse in adherence to these guidelines.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to ensure that food was served in a palatable and presentable manner for three residents. One resident, who was a newer admission for rehabilitation, expressed dissatisfaction with the taste and variety of the food, stating it was their main concern as they could barely eat their meals. Another resident reported that the food was horrible, specifically mentioning that the eggs tasted like they were powdered and the bread was old and hard. A third resident described the food as terrible, noting that the grits were solid enough to be lifted with a fork and that the French toast was often cold. This resident also criticized the presentation of the food, stating that the meat sometimes tasted old and the gravy was insufficient. The facility's dietary staff acknowledged the residents' complaints, with a kitchen staff member confirming that scrambled eggs were made from a liquid egg product, which some residents compared to powdered eggs. The Dietary Manager and District Manager explained that the chicken pot pies were made in a large bowl with biscuits baked on top, which differed from the whole pies previously served. The facility's Nutritional Services policy did not address food palatability, resident preferences, or presentation, and the Nursing Home Administrator and Director of Nursing indicated that these concerns should be addressed by dietary management staff.
Failure to Provide Non-Allergenic Food to Resident
Penalty
Summary
The facility failed to provide non-allergenic food to a resident, R13, who has a documented seafood allergy. On the evening of 12/09/24, R13 was served Shrimp [NAME] for dinner, which they mistakenly believed was Chicken [NAME]. Upon realizing the error, R13 experienced a tingling sensation in their mouth and tongue, indicative of an allergic reaction, and immediately spit out the food. A Certified Nurse Assistant (CNA) present at the time notified the Licensed Practical Nurse (LPN) S, who administered Benadryl to R13. Despite the incident, there was no documentation of the allergic reaction in R13's medical records, including progress notes, assessments, or orders. The facility's dietary management confirmed that R13's seafood allergy was clearly marked on their meal ticket, and it was the responsibility of both the cook and dietary staff to ensure meals were served according to these designations. However, the incident was not communicated to the Assistant Director of Nursing (ADON) or documented in the medical records, indicating a lapse in communication and documentation protocols. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the incident, acknowledging the occurrence and the resident's reaction. The facility's Nutritional Management policy, dated 1/2024, mandates that food allergies and intolerances be identified and noted on tray cards, which was not adhered to in this case.
Failure in Infection Control and PICC Line Management
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident, identified as R346, who was observed with a sign on their door indicating contact precautions due to an infection in their dialysis access site. Despite the sign, multiple staff members, including a respiratory therapist, a certified nurse assistant, a social worker, and a nurse practitioner, were observed not adhering to the required precautions. These staff members either did not wear the necessary personal protective equipment (PPE) such as gowns and gloves or failed to perform hand hygiene after providing care to R346. The Director of Nursing confirmed that R346 was on transmission-based precautions for C. auris and that all contact with the resident required PPE. Additionally, the facility failed to ensure timely dressing changes for a peripherally inserted central catheter (PICC) line for another resident, identified as R25. The resident reported having a PICC line in their right upper arm, with a dressing dated 12/2/24, which had not been changed as per the physician's order. The dressing was supposed to be changed every seven days, but records showed that eight different nurses documented monitoring the site without changing the dressing. The Director of Nursing confirmed that the PICC line should have been discontinued after the completion of antibiotics and that the dressing should be changed weekly. The facility's policies on infection prevention and control, as well as vascular access management, were not adhered to, leading to these deficiencies. The infection prevention policy required staff to follow transmission-based precautions and use PPE as per CDC guidelines, while the vascular access management policy required dressing changes every five to seven days. The failure to comply with these policies resulted in the observed deficiencies in infection control practices and PICC line management.
Deficiencies in Hygiene and Meal Assistance
Penalty
Summary
The facility failed to provide adequate hygiene care for a resident who had not received a shower in over a month. The resident, who was incontinent, non-ambulatory, and required assistance with bathing, reported that despite being scheduled for showers twice a week, they were not offered or were told it could not be done. The facility's records showed only two documented instances of showers being offered and refused, with no additional showers documented over a period of several weeks. The Director of Nursing confirmed that the resident should have been offered showers twice weekly and as needed, in accordance with the facility's policy on activities of daily living. Another deficiency was identified in the facility's failure to provide meal assistance to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident was observed multiple times with uneaten meals and nutritional drinks left untouched, despite having a physician's order for 1:1 assist feeding due to their inability to self-feed. The resident's care plan indicated a need for assistance with activities of daily living, including eating, and highlighted the resident's nutritional risk due to poor appetite and failure to thrive. Despite this, the resident was not consistently provided with the necessary assistance during meals, as observed by surveyors. The facility's policy on activities of daily living stated that residents who are unable to carry out these activities should receive the necessary services to maintain good nutrition and hygiene. However, the observations and interviews conducted during the survey revealed that the facility did not adhere to this policy, resulting in deficiencies in both hygiene care and meal assistance for the residents involved.
Failure to Apply Lymphedema Wraps and Reposition Resident
Penalty
Summary
The facility failed to apply lower extremity lymphedema wraps for a resident diagnosed with heart failure and bilateral lower extremity swelling. The resident reported that their legs had not been wrapped for edema for two consecutive days, despite a physician's order to wrap the legs daily. Observations confirmed that the resident's legs were not wrapped on multiple occasions, and the resident expressed concern about increased swelling affecting their therapy progress. The Director of Nursing acknowledged that the wraps should be applied daily as ordered, and the facility's policy mandates that care and services be provided according to accepted standards of clinical practice. Additionally, the facility failed to reposition another resident who was unable to reposition themselves due to severe cognitive impairment and a stage 2 wound on the coccyx. The resident was observed lying in bed in the same position over several days without a positioning wedge, which was necessary for their care. Interviews with staff confirmed that the resident required extensive assistance with activities of daily living and needed to be repositioned every two hours. The Director of Nursing confirmed that the resident should have a positioning wedge and be repositioned regularly, as outlined in the facility's policy on activities of daily living.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to provide adequate tube feeding and hydration for a resident who was observed multiple times without their tube feeding connected. The resident's tube feeding bottle was dated two days prior and was not infusing, despite physician orders for continuous feeding and water flushes. The resident, who had intact cognition, reported feeling hungry, and the Licensed Practical Nurse confirmed the feeding was not administered as ordered. The Registered Dietician emphasized the importance of adjusting feeding orders to meet caloric needs, and the Director of Nursing confirmed the resident should have received the feeding as prescribed. Another deficiency was identified in the facility's failure to provide meal assistance and nutritional supplements to a resident with severe cognitive impairment. The resident was observed with uneaten meals and without the prescribed nutritional supplements. Despite physician orders for 1:1 feeding assistance and nutritional shakes with meals, the resident did not receive the necessary support. The resident's weight had decreased, and the Registered Dietician confirmed the need for nutritional supplements three times a day. The facility's policies on enteral feeding and nutrition management were not followed, leading to these deficiencies. The policies outlined the need for adherence to physician orders and the involvement of a Registered Dietitian in assessing and meeting residents' nutritional needs. However, the observations and interviews revealed a lack of compliance with these policies, resulting in inadequate nutrition and hydration for the residents involved.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, leading to a deficiency. The resident, who had a history of witnessing a traumatic event, was issued an involuntary discharge notice without prior awareness, which triggered a traumatic reaction. The discharge plan involved sending the resident to a homeless shelter, which escalated their behavior, resulting in verbal aggression and threats. The facility's social services notes confirmed the lack of prior notification and the resident's refusal to sign the discharge notice. The resident's care plan, initiated months earlier, did not include any interventions to identify or address triggers related to their PTSD. The care plan only included general interventions such as educating the resident on expressing feelings and providing reassurance of a safe environment. There was no documentation of a PTSD assessment or identification of specific triggers and effective interventions in the resident's social services assessments or behavioral logs. Interviews with facility staff, including the Nursing Home Administrator and social services personnel, revealed a lack of awareness of the resident's PTSD diagnosis until after the incident. The facility's policy on trauma-informed care emphasized the importance of identifying triggers and implementing individualized care plan interventions, but these were not in place for the resident. The facility acknowledged the deficiency in documentation and the need for improvement in addressing the resident's trauma-related needs.
Failure to Reposition Resident with Pressure Wound
Penalty
Summary
The facility failed to ensure timely repositioning of a resident with a known pressure wound, leading to a deficiency in skin care management. On multiple observations throughout the day, the resident was found lying on their back without any repositioning or use of pillows to offload pressure from the sacral wound, despite the care plan indicating the need for routine repositioning and assistance with bed mobility. The resident, who has paraplegia and heart failure, was admitted with a stage three pressure ulcer and requires substantial assistance to reposition. The facility's policy on wound prevention and management emphasizes the importance of redistributing pressure for residents at risk of pressure injuries. However, the observations revealed that the resident was not repositioned every two hours as expected, and no devices or pillows were used to alleviate pressure on the sacral wound. The resident reported experiencing constant pain from the wound, and the Director of Nursing acknowledged the expectation for repositioning every two hours, which was not met.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R705, who was observed multiple times throughout the day with a soaked incontinence pad and wet bedding. Despite the presence of clean linens and briefs at the foot of the bed, the resident remained unchanged from the morning until the afternoon. The resident, who has Alzheimer's Disease and Bilateral Lower Extremity Contracture, was unable to recall when they were last changed and could not clearly express their feelings about being wet for an extended period. The Certified Nurse Assistant (CNA) responsible for R705's care confirmed that the resident was only changed once in the morning, around 7-7:30 AM, and not again until 2 PM. The Director of Nursing (DON) acknowledged that this was not acceptable, as the facility's policy requires checks and changes approximately every two hours and as needed. The facility's policy on Activities of Daily Living emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to carry out these activities themselves.
Failure to Follow Hospital Discharge Instructions
Penalty
Summary
The facility failed to adhere to hospital discharge instructions and orders for a resident diagnosed with Multiple Myeloma, who was cognitively intact and required moderate to maximum assistance for Activities of Daily Living. The discharge instructions included scheduling follow-up appointments with specialists in medical oncology, family medicine, and neurological surgery, as well as an outpatient MRI. However, only the medical oncology appointment was scheduled, and there was no documentation indicating that the resident attended any of the scheduled appointments. Interviews with facility staff revealed that the resident or their daughter canceled the initial oncology appointment, and subsequent appointments were rescheduled but not documented as attended. The Assistant Director of Nursing acknowledged the lack of documentation and mentioned that the staff member responsible for scheduling appointments was no longer employed at the facility. The Nursing Home Administrator noted concerns about transportation arrangements for the resident, who preferred to be transported by stretcher but did not meet the criteria. The facility's Physician Orders policy outlines the responsibility to maintain a schedule of diagnostic tests and consultations, and to arrange transportation for off-site services, which was not adequately followed in this case.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, who was initially admitted with diagnoses including End Stage Renal Disease, Type II Diabetes Mellitus, Morbid Obesity, and Hypertension, was cognitively intact and dependent on staff for transfers and toilet use. An incident occurred where the resident threw a feces-filled washcloth at a CNA, leading to the involvement of the police and the resident being sent to a local hospital for psychiatric evaluation. Despite being medically and psychiatrically cleared to return, the facility refused to accept the resident back, citing a lack of staff to care for him due to his aggressive behavior and non-compliance with care. The facility's Director of Nursing reported that the resident had a history of aggressive behavior towards staff, including hitting and belittling them, and often refused care while complaining about unmet needs. The facility's refusal to readmit the resident was based on these behavioral issues and the claim that they could not meet his needs. The facility's Transfer and Discharge policy outlines specific exemptions for discharge, including when a resident's needs cannot be met or when the safety of individuals in the facility is endangered. The facility's actions were based on these exemptions, as they claimed the resident's behavior endangered staff safety and that they lacked the resources to manage his care. An administrative hearing was scheduled to address the involuntary discharge.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R700, who was found missing from their room during a routine check by the midnight staff. The incident occurred outside the facility, and it was discovered that R700 had left the premises without any injuries observed at the time. The resident, who had a history of schizoaffective disorder and stroke, was noted to have severely impaired cognition and required assistance for all activities of daily living. The elopement was reported to the police, and the resident was returned to the facility without signs of distress or injury. Interviews with staff members revealed lapses in supervision and response to alarms. A Certified Nurse Assistant (CNA) assigned to R700 last saw the resident at approximately 9:30 PM and noted that an alarm had sounded after 10:00 PM. However, the alarm was turned off by another employee, and a food delivery was placed near the alarming door. Another CNA, who conducted a bed check at 11:45 PM, was unable to locate R700 and did not recall hearing any alarms prior to the discovery of the resident's absence. The facility's policy on elopement risk and missing residents, which requires care team members to know the location of residents and take appropriate action in case of a missing resident, was not effectively implemented. The Nursing Home Administrator reviewed the incident investigation, but the report indicates that the facility's procedures and processes for elopement were not revised following the incident.
Failure to Implement Timely Wound Care
Penalty
Summary
The facility failed to implement timely treatments for a newly identified wound for a resident, resulting in the worsening of the wound. The resident was admitted with diagnoses including cerebral infarction, dysphagia, and adult failure to thrive, and had impaired cognition with a mental status score of 7/15. Initially, the resident did not have any identified skin conditions. However, on January 14, 2024, a dime-sized open area was noted on the resident's sacrum, but no wound care treatment order was entered at that time. The wound progressed to a stage 3 pressure ulcer by January 26, 2024, measuring 1.0 cm x 1.0 cm x 0.1 cm, yet still lacked a physician's order for treatment. It was not until February 2, 2024, that a treatment order was documented. By July 11, 2024, the wound had worsened to 8.0 cm x 6.5 cm x 0.0 cm, remaining unchanged in stage. The Director of Nursing acknowledged that an order should have been entered at the time of the initial observation, as per the facility's policy to implement evidence-based interventions for residents at risk or with existing pressure injuries.
Failure to Honor Resident Self-Determination in LOAs
Penalty
Summary
The facility failed to honor the residents' rights to self-determination regarding Leave of Absences (LOAs), potentially affecting all 95 residents. The Nursing Home Administrator (NHA) implemented restrictions on LOAs, which included specific times residents could leave, activities that could restrict LOAs, weather-related restrictions, and the requirement for residents to be accompanied by a community member during LOAs. These restrictions were established after discussions with the medical director, law enforcement, local business owners, and community members due to concerns about resident behaviors in the community, such as panhandling and inappropriate conduct in local businesses. The LOA guidelines stated that residents could only sign out between 8 AM and 8 PM, and during inclement weather, they must be accompanied by an adult. Residents leaving outside these hours without accompaniment would face discharge against medical advice. The guidelines also prohibited residents from possessing cigarettes, lighters, weapons, marijuana, alcohol, or other intoxicants. The facility's Therapeutic Leave policy allowed residents to leave for non-medical visits in accordance with federal and state guidelines, but the new restrictions contradicted this policy. The Director of Nursing (DON) mentioned Medicaid insurance requirements but did not address the residents' rights.
Inconsistent Resident Council Meetings
Penalty
Summary
The facility failed to consistently assist the Resident Council in holding their monthly meetings, as identified during a mock survey. The Nursing Home Administrator (NHA) acknowledged the deficiency and presented a folder containing incomplete or undated resident council meeting notes. The facility's Resident Council policy emphasizes the importance of these meetings as a platform for residents to provide input on the facility's operations, discuss group concerns, and facilitate communication between residents and staff. The deficiency was partly attributed to the turnover of three Activity Directors within the past year, which contributed to the disorganization of the Resident Council meeting records. The facility's policy mandates that Resident Council meetings occur monthly, specifically every third Wednesday, with the participation of the president, residents, and the Activity Director. However, the review of the Resident Council minutes revealed missing dates and disordered records, indicating a failure to adhere to the policy and support the residents' rights to organize and participate in these meetings.
Lack of Qualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, potentially affecting all 95 residents. During an interview, the Nursing Home Administrator (NHA) revealed that a new Activities Director was hired last month, as there was no one in the position when he assumed his role. The Activities Director confirmed her start date as June 10, 2024, and an Activities Aide stated that since her start in April 2024, there had been no Activities Director. The Director of Nursing (DON) recalled that the last Activities Director was in place in March 2024. A review of the Activities Policy did not provide information regarding a qualified professional.
Elopement Incident Involving Resident with Schizoaffective Disorder and Vascular Dementia
Penalty
Summary
The deficiency reported in the survey pertains to the failure of a long-term care facility to provide adequate monitoring, supervision, and response to prevent the elopement of a resident identified as an elopement risk. The resident in question, identified as R901, had diagnoses including Schizoaffective Disorder-Bipolar Type, Anxiety Disorder, Violent Behavior, and Vascular Dementia. Despite being considered at risk for elopement and wearing a Wanderguard ankle bracelet, R901 managed to leave the facility undetected on the evening of 03/25/24. Staff only became aware of the elopement approximately eight hours later, leading to a significant delay in locating the resident. The facility's records indicated that R901's care plan included interventions such as redirecting the resident when wandering or exit-seeking and the use of a Wanderguard ankle bracelet. However, despite these measures, R901 was able to exit the facility without staff awareness. Interviews with staff members revealed discrepancies in their recollection of events, with some not recalling hearing any door alarms on the evening of the elopement. Surveillance footage from a nearby business indicated that R901 had been outside the facility for several hours before staff realized they were missing.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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