Maple Manor Rehab Center Of Novi Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Novi, Michigan.
- Location
- 31215 Novi Road, Novi, Michigan 48377
- CMS Provider Number
- 235669
- Inspections on file
- 15
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Maple Manor Rehab Center Of Novi Inc during CMS and state inspections, most recent first.
A high fall-risk resident with a history of femur fracture and multiple comorbidities was care-planned to ambulate with CGA and a walker, as indicated by a red tag on the walker and facility policy requiring gait belt use for residents who cannot ambulate independently. One night, a CNA assisted the resident to the bathroom and then allowed the resident to walk back toward the bed without using a gait belt and without maintaining contact guard, remaining too far away to intervene when the resident lost balance, became entangled in the walker, and fell. The resident was found on the floor with multiple skin tears and a bleeding forehead laceration that required hospital treatment and sutures. Subsequent interviews with the CNA, Rehab Director, and DON confirmed that the resident should have had hands-on CGA and likely a gait belt during ambulation, but these interventions were not implemented at the time of the fall.
During an influenza outbreak, the facility failed to implement consistent infection control practices and an effective surveillance program. Staff did not adhere to PPE protocols, and the Infection Control Preventionist provided inconsistent guidance. The facility's infection surveillance was incomplete, and there was a delay in reporting the outbreak to the health department. Specific incidents included staff entering precaution rooms without proper PPE and inadequate equipment cleaning, contributing to the facility's failure to control the outbreak.
The facility's wireless call light system was not fully operational, affecting all residents' ability to summon help. Residents, including those with significant medical needs, reported long wait times and ineffective alternative solutions like bells. Staff interviews and observations revealed issues with the system's Wi-Fi connection and lack of regular audits, leading to unreliable service. The facility's policy on call light accessibility and timely response was not met due to these deficiencies.
Two residents in a LTC facility were found with position change alarms without appropriate assessments or physician orders. One resident, with Alzheimer's, had alarms in their wheelchair and bed without documented justification or attempts at less restrictive measures. Another resident, cognitively intact, had a bed alarm despite being able to request assistance. Interviews revealed inconsistencies in the facility's process for alarm use, and the Director of Nursing acknowledged the lack of documentation and assessments.
A resident with quadriplegia and hand contractures was observed without required hand splints, despite a care plan indicating their use. Staff interviews revealed inconsistency and lack of awareness regarding the splints, with some using rolled washcloths instead. The Director of Rehab and DON were unaware of the splints' status, highlighting a lack of oversight in implementing the care plan.
A facility failed to consistently administer oxygen therapy as ordered for a resident with sepsis and delirium. The resident was observed with disconnected or improperly placed oxygen tubing on two occasions, contrary to the physician's order for oxygen via nasal cannula at 2 LPM. Despite the need for assistance with all ADLs, no care plan or interventions were documented for the resident's non-compliance with oxygen therapy. The DON was unaware of the issue and stated that interventions could have been implemented if informed.
The facility failed to document indications for medications for two residents, contrary to its policy. One resident, readmitted with a femur fracture, had orders for Bupropion, Trazodone, and Xanax without indications. Another resident, with atrial flutter and heart failure, had orders for Eliquis and Hydrocodone-acetaminophen also lacking indications. The DON acknowledged the issue and mentioned plans to ensure indications are documented in the future.
The facility failed to ensure PRN psychotropic medications had a stop date and did not attempt non-pharmacological interventions before administration for two residents. One resident received alprazolam without an end date, and another received Xanax beyond the 14-day limit without justification. The facility's policy requires PRN orders to be limited to 14 days and non-pharmacological interventions to be attempted first, which was not followed.
The facility did not maintain a system to monitor antibiotic use, affecting residents prescribed antibiotics. The February 2025 Infection Control Form showed incomplete documentation, with infections not assessed for criteria, resolution, or origin. The ICP was too busy to maintain data and relied on McGeer checklists at nurses' stations. The facility's policy on the Antibiotic Stewardship Program was not effectively implemented.
A resident with intact cognition and a history of orthostatic hypotension and shingles was placed on a position change alarm without a physician order, care plan intervention, or documented assessment, contrary to facility policy. Staff interviews revealed confusion about alarm use procedures, and the DON confirmed the lack of documentation. Additionally, a CNA failed to follow contact precautions and infection control protocols when entering the resident's room, including not using PPE or performing hand hygiene.
Two residents received PRN anti-anxiety medications with open-ended orders and without required documentation justifying use beyond 14 days. Medical records lacked evidence of non-pharmacological interventions being attempted or documented prior to medication administration, contrary to facility policy. The DON acknowledged these deficiencies during interviews.
Surveyors found that staff inconsistently followed droplet precaution protocols for two residents with influenza, including improper use of PPE and inadequate cleaning or dedication of equipment. Staff interviews revealed confusion about required PPE and cleaning procedures, and signage did not align with facility policy, resulting in deficient infection control practices.
Several residents with significant care needs were unable to reliably summon staff due to a malfunctioning wireless call light system, which frequently lost WiFi signal and lacked regular maintenance checks. Residents resorted to using hotel-like bells that were not audible when doors were closed, and staff were not consistently notified of calls for assistance. Staff interviews confirmed that pagers and alert systems were not always used or functional, and maintenance only responded to complaints rather than conducting routine audits.
A facility failed to maintain consistent dialysis communication documentation and assessments for a resident with end-stage renal disease. The last documented dialysis communication/assessment was nearly a year old, despite the resident receiving dialysis care five days a week. The DON confirmed that the records had not been uploaded to the resident's medical record since May 2023.
The facility failed to provide a privacy cover over an indwelling catheter bag for a resident. On multiple occasions, the resident was observed without a dignity privacy bag covering the catheter bag. The DON confirmed that the resident should have had a dignity privacy bag and that nursing staff are responsible for ensuring these are in place. The resident had diagnoses of Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, and was cognitively intact.
The facility failed to ensure that the code status and treatment preferences of three residents were clearly documented in their clinical records, leading to inconsistencies between the hard chart and the EMR.
A resident with hearing loss and hearing aids did not have a care plan addressing these concerns. The MDS Coordinator acknowledged the oversight, and the DON confirmed that it was the MDS Coordinator's duty to create the care plan.
A resident with a traumatic brain injury and severely impaired cognition had multiple instances of redness and open skin on the coccyx and buttocks documented in the MAR from February to April 2024. However, there was no documented assessment of the wounds, and an observation revealed bloody drainage and partial thickness skin loss, contradicting earlier documentation that the wound had resolved.
The facility failed to consistently document urinary output for a resident with an external catheter, despite the care plan requiring monitoring and documentation every shift. The DON confirmed the requirement, but multiple instances of undocumented outputs were found across January, February, and March 2024.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident was prescribed antibiotics for a productive cough associated with COVID-19 without documented justification, while another was given Cipro for a UTI despite a negative urine culture. Interviews revealed that the facility did not review antibiotics prescribed at the hospital, leading to inadequate documentation and adherence to protocols.
Failure to Provide Required Contact Guard Assist and Gait Belt Use Resulting in Resident Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement required fall-prevention interventions and adequate supervision for a high fall-risk resident, resulting in a fall with injuries. The resident was admitted with a history of a fall with femur fracture and other diagnoses including diabetes, COPD, UTI, urinary retention, and adjustment disorder. A fall risk assessment completed in December scored the resident as an 18, which the facility defined as high fall risk. The resident’s walker had a red tag indicating the need for contact guard assist (CGA) and use of a gait belt when ambulating, and the facility’s policy required residents who could not independently ambulate or transfer to use a gait belt for safety. On the night of the incident, a nurse documented that around 1:15 a.m. a loud sound was heard from the resident’s room, and the nurse found the resident sitting on the floor with the walker between their legs, bleeding from the forehead with a right arm skin tear and bilateral leg skin tears. The resident was sent to the hospital and later returned with sutures to the forehead, bruising to the left temporal area, and dressings and steri-strips to multiple skin tears. A physician note referenced a mechanical fall with scalp laceration requiring sutures. The resident and family later reported via a complaint form that the resident, who used a walker and was recovering from surgical repair of a broken femur, had been assisted to the bathroom by an aide and fell while walking back toward the bed because the aide did not physically support the resident. During the facility’s investigation, the resident initially alleged that the CNA pushed them, but provided inconsistent statements. Another CNA reported that the resident and the resident’s daughter stated the aide involved was not close enough to prevent the fall. In a telephone interview, the CNA who assisted the resident acknowledged answering the call light, assisting the resident to the bathroom, and then allowing the resident to ambulate back to the bed with a walker. The CNA stated the resident lost balance while backing toward the bed, became tangled in the walker, and fell, and admitted they were not close enough to get a hand on the resident to prevent the fall. The CNA further acknowledged knowing the red tag on the walker meant the resident required CGA and a gait belt, but they did not provide contact guard assist or use a gait belt at the time of the fall. The Rehabilitation Director and DON both confirmed that CGA required staff to be right next to the resident with a hand on or near them and that a gait belt should have been used for this resident.
Inadequate Infection Control During Influenza Outbreak
Penalty
Summary
The facility failed to consistently implement infection control standards and practices, as well as an effective infection control surveillance program, during an influenza outbreak affecting all 47 residents. Upon entry, surveyors were informed of the outbreak and observed inadequate infection control measures, such as staff not wearing the required personal protective equipment (PPE) like gowns, despite signage indicating droplet precautions. The Infection Control Preventionist (ICP) and staff provided inconsistent information regarding PPE requirements, and the facility's policy was not followed, leading to potential exposure risks. The infection surveillance program was found lacking, with no documentation for February 2025 and incomplete mapping of infections from May 2024 to March 2025. The ICP admitted to taking surveillance documents home due to covering two buildings, resulting in delayed reporting to the local health department. The facility failed to timely identify, report, and control the outbreak, as evidenced by the delayed notification of the health department and the lack of real-time infection control data review, despite the ongoing outbreak. Specific incidents highlighted the facility's deficiencies, such as a CNA entering a resident's room under contact precautions without proper PPE and failing to perform hand hygiene. Another staff member was observed improperly cleaning equipment used in a droplet precaution room, and there was confusion among staff about the correct PPE protocol. These actions and inactions contributed to the facility's failure to adhere to infection control standards, potentially exacerbating the outbreak and putting residents and staff at risk.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that its wireless call light communication system was fully operational, affecting all residents, including those with significant medical needs. Observations revealed that residents were unable to summon help effectively due to the malfunctioning call light system. For instance, one resident, who was in pain and waiting for medication, reported that their call light was not functioning, and their roommate had to use a bell to attempt to summon help. Another resident expressed concerns about the ineffectiveness of the bell provided as an alternative, especially with doors closed due to a flu outbreak. The facility's call light system was found to be unreliable, with issues such as loss of Wi-Fi signal and incorrect date and time settings on the alert system. Staff interviews confirmed that the system frequently lost connection, and pagers, which were part of the system, were not being used consistently. Maintenance staff admitted to not conducting regular audits of the call light system, instead relying on complaints to address issues. This lack of proactive monitoring contributed to the ongoing problems with the call light system. The facility's policy required that call lights be accessible and that staff respond promptly to alerts. However, the system's deficiencies, including the lack of a hard-wired connection and reliance on a faulty wireless network, hindered compliance with this policy. The Director of Nursing and Assistant Administrator acknowledged the system's shortcomings and the need for a new system, but at the time of the survey, the existing system remained inadequate, leaving residents without a reliable means to summon assistance.
Failure to Document and Justify Use of Position Change Alarms
Penalty
Summary
The facility failed to ensure appropriate assessments and physician orders were completed for the use of position change alarms for two residents, R6 and R342. R6 was admitted with multiple diagnoses including Alzheimer's disease and was observed with a position change alarm in both their wheelchair and bed. However, there was no documentation in R6's electronic medical record (EMR) indicating a medical symptom or diagnosis that warranted the use of these alarms. Additionally, there was no evidence of any least restrictive approaches being attempted prior to the use of the alarms, nor were there any nursing or interdisciplinary assessments recommending their use. R6's care plan did not mention the use of position change alarms, and the facility's progress notes lacked any rationale for their use. R342, admitted for short-term skilled nursing and rehabilitation care, was also observed with a position change alarm attached to their bed. Despite having a history of near falls due to orthostatic hypotension, R342 was cognitively intact and able to ask for assistance. The EMR for R342 did not contain any orders for the use of position change alarms, nor did it document any medical symptoms justifying their use. Similar to R6, there was no evidence of any nursing or interdisciplinary assessments recommending the alarms, and no documentation of other less restrictive measures being attempted. R342's care plan and Minimum Data Set (MDS) assessment did not mention the use of position change alarms. Interviews with Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) revealed a lack of clarity and consistency in the facility's process for determining the use of position change alarms. The CNAs indicated that alarms were used for residents deemed at risk of falls, but they were unsure of the process and who made the final determination. The DON acknowledged the absence of documentation and assessments for R6 and R342, understanding the concern raised by the surveyors. The facility's policy on resident alarms emphasized the need for alarms to be used in limited circumstances, based on a comprehensive assessment of the resident's needs, goals, and preferences, which was not adhered to in these cases.
Failure to Implement Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to implement a positioning device, specifically hand splints, for a resident (R16) who was reviewed for positioning and range of motion services. R16, a long-term resident with a history of traumatic brain injury, quadriplegia, and seizures, was observed multiple times without any hand splints or braces, despite having bilateral hand contractures. The care plan for R16, initiated in September 2020, required the use of splints on both hands at night to prevent injury, skin breakdown, edema, atrophy, and contractures. However, observations on consecutive days revealed that R16's hands remained in a clawed position without any splints or devices in place. Interviews with staff members, including an LPN and a CNA, indicated a lack of awareness and inconsistency in the use of hand splints for R16. The LPN, who was familiar with R16, reported never having seen any splints for the resident and confirmed their absence in the room. Similarly, the CNA, who regularly worked with R16, noted that the use of rolled washcloths was inconsistent and dependent on the staff member assigned to the resident. The CNA care plan did mention the requirement for hand splints, but the actual practice did not reflect this plan. Further interviews with the Director of Rehab and the Director of Nursing revealed a lack of oversight and follow-up regarding the implementation of the care plan for R16. The Director of Rehab was unaware of the current status of R16's splints and suggested that the splints might have been missed after the resident's readmission from the hospital. The Director of Nursing acknowledged the concern and the absence of a plan to maintain R16's range of motion, indicating a gap in ensuring that CNAs followed the care plan and documented appropriately.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that oxygen therapy was consistently administered as ordered by the physician for a resident identified as R14. On two separate occasions, R14 was observed with their oxygen tubing disconnected or improperly placed, which was not in accordance with the physician's order for oxygen via nasal cannula at 2 LPM to maintain an oxygen saturation of 90% or greater. The first incident occurred when R14 was found with the oxygen tubing disconnected from the concentrator, and the LPN had to reconnect it. The LPN mentioned that R14 often removed the tubing themselves. The second incident involved R14 sleeping with the nasal cannula improperly placed on their upper lip, requiring an RN to reapply it and remind R14 to keep it on. The medical record review revealed that R14 was admitted with diagnoses including sepsis and delirium and required assistance for all ADLs. Despite the physician's order for oxygen therapy, there was no care plan or interventions documented for R14's non-compliance with oxygen therapy. The facility's policy on oxygen administration requires that care plans identify interventions for oxygen therapy based on assessments, but this was not implemented for R14. The Director of Nursing was unaware of R14's non-compliance and stated that interventions could have been implemented if they had known about the issue.
Failure to Document Indications for Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications had an indication for use and did not transcribe physician orders according to the facility policy for two residents. Resident 5 was observed receiving oxygen via nasal cannula and had been readmitted with a diagnosis of a fracture of the lower end of the left femur. The medical record review showed that the physician orders for Bupropion, Trazodone, and Xanax did not include an indication for use, with staff documenting 'N/A' in the diagnosis section. This was contrary to the facility's medication order policy, which requires a diagnosis or indication for use. Similarly, Resident 7, who was readmitted with atrial flutter and heart failure, had physician orders for Eliquis and Hydrocodone-acetaminophen that also lacked documented indications for use, with 'N/A' noted in the diagnosis section. During an interview, the Director of Nursing acknowledged that the indications are typically included in the physician's progress notes and stated that a process would be implemented to ensure the indication section is completed when transcribing medication orders. No further explanation or documentation was provided by the end of the survey.
Failure to Implement PRN Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had a stop or end date and did not attempt non-pharmacological interventions before administering these medications to two residents, R5 and R12. R12, who was admitted with multiple diagnoses including generalized anxiety disorder, was prescribed alprazolam on a PRN basis without an end date. The medication was administered multiple times over a month for reasons such as behavior issues and pain, but there was no evidence of non-pharmacological interventions being attempted prior to its administration. The Director of Nursing (DON) acknowledged the lack of an end date and the absence of documentation for non-pharmacological interventions. Similarly, R5 was prescribed Xanax on a PRN basis with an open-ended order, which extended beyond the 14-day limit without documented justification from the prescribing practitioner. The medication was administered on several occasions, yet there was no documentation of non-pharmacological interventions being attempted before its use. The DON confirmed that the order should have had a stop date and that staff should have documented interventions prior to administering the medication. The facility's policy on the use of psychotropic medications, revised in January 2025, stipulates that PRN orders for such medications should be limited to 14 days unless extended with documented rationale. It also requires non-pharmacological interventions to be attempted before administering psychotropic medications. The facility's failure to adhere to these policies resulted in deficiencies related to the administration of PRN psychotropic medications for R5 and R12.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to consistently maintain a system that monitored antibiotic use, potentially affecting any resident prescribed an antibiotic among the 47 residents in the facility. A review of the facility's February 2025 Infection Control Form revealed five pages of documented infections, none of which were assessed to meet or not meet the criteria for infection, with sections left blank. Additionally, infections were not identified as resolved, ongoing, nosocomial, or community-acquired, and signs and symptoms were often not noted. The surveillance log was incomplete. The Infection Control Preventionist (ICP) admitted to being too busy to maintain the data and relied on the McGeer checklist posted at nurses' stations for guidance, without further explanation. The facility's policy on the Antibiotic Stewardship Program, revised in January 2025, stated the use of updated McGeer criteria to define infections, but this was not effectively implemented.
Failure to Document and Assess Use of Position Change Alarms and Lapses in Infection Control
Penalty
Summary
A resident was admitted to the facility following hospitalization, with diagnoses including orthostatic hypotension, muscle weakness, and later, shingles. The resident was cognitively intact, able to use the call light, and could request assistance. Despite this, a position change alarm was observed in use for the resident, with no corresponding physician order, care plan intervention, or interdisciplinary assessment recommending its use. Documentation in the electronic medical record did not support the use of the alarm, and there was no evidence that less restrictive interventions were attempted prior to its implementation. Staff interviews revealed uncertainty about the process for determining alarm use, with CNAs indicating that alarms were often used for fall risk residents, sometimes at their own discretion, and without clear guidance or assessment documentation. The facility's policy required that alarms be used only in limited circumstances, based on individualized assessment, documented medical symptoms, and after considering less restrictive interventions. However, the resident's records lacked documentation of such assessments, orders, or care plan entries for the alarm. The DON confirmed that there was no documentation supporting the use of alarms for the resident and acknowledged the concern. The policy also required communication of interventions to all relevant staff, which was not evident in this case. Additionally, infection control deficiencies were observed. The resident was on contact precautions due to a diagnosis of shingles, with clear signage and physician orders requiring hand hygiene and the use of personal protective equipment (PPE) upon entering the room. A CNA was observed entering the resident's room without performing hand hygiene or donning PPE, touching the resident's environment, and improperly handling their face mask. The CNA was unaware of the correct reason for contact precautions and did not follow required infection control protocols, despite care plan and physician order instructions.
Failure to Limit and Document PRN Psychotropic Medication Use and Non-Pharmacological Interventions
Penalty
Summary
Two residents were found to have ongoing PRN (as needed) orders for anti-anxiety medications, specifically alprazolam and Xanax, without appropriate stop dates or documented clinical justification for extending the orders beyond 14 days. The facility's own policy, consistent with federal regulations, requires that PRN psychotropic medications be limited to 14 days unless the prescribing practitioner documents a rationale for extension and specifies a duration. In both cases, the orders were open-ended and lacked the required documentation from the prescribing practitioner to justify continued use beyond the 14-day limit. Additionally, the medical records for both residents did not contain evidence that non-pharmacological interventions were attempted or documented prior to the administration of the PRN psychotropic medications. The facility's policy mandates that non-pharmacological approaches be used and documented before resorting to psychotropic medications unless clinically contraindicated. However, the Medication Administration Records (MAR) and nursing progress notes did not reflect any such interventions or monitoring of target behaviors before administering the medications. Interviews with the Director of Nursing (DON) confirmed awareness of the requirements for stop dates and documentation of non-pharmacological interventions, but acknowledged that these were not followed in the cases reviewed. The lack of adherence to policy and regulatory requirements regarding psychotropic medication management and documentation led to the identified deficiencies.
Deficient Infection Control Practices for Droplet Precautions
Penalty
Summary
Surveyors observed that a resident's room was under droplet precautions for influenza, as indicated by signage and the presence of a PPE cart outside the room. Staff interviews revealed inconsistent understanding and implementation of droplet precaution protocols. The Infection Preventionist stated that staff should wear a surgical mask, face shield, and gown, but the signage only required a mask and face shield, and staff reported that gown use was optional or no longer required. A physical therapy assistant was seen donning a gown, gloves, and mask, but only sanitized the finger area of a vital sign machine after use in the resident's room, despite signage indicating the need for dedicated or disposable equipment. The assistant confirmed that there was no dedicated equipment for that area and that only part of the machine was cleaned before it was taken into the hallway. Further interviews with staff showed confusion about proper PPE donning and doffing procedures, with some staff stating that gowns were not necessary and that face shields should be cleaned in the hallway rather than in the resident's room. The Infection Preventionist clarified that face shields should be cleaned in the room, but this was not consistently practiced. The residents involved had recent diagnoses of influenza and other significant medical conditions, and one resident confirmed ongoing illness. The observations and interviews demonstrate a deficiency in the facility's implementation and staff understanding of infection control protocols for droplet precautions, including the use of PPE and cleaning or dedicating equipment.
Failure to Maintain Functional Call Light System for Resident Safety
Penalty
Summary
Multiple residents were observed to have non-functioning or unreliable call light systems in their rooms, which impeded their ability to request assistance from staff. One resident, who had intact cognition and required assistance with most activities of daily living, reported that their call light did not work and that maintenance had attempted repairs several times without success. This resident resorted to using a hotel-like bell, which was not audible when the door was closed, and staff did not respond to the bell on at least one occasion. Another resident, who was wearing a sling and used a wheelchair, also relied on a hotel-like bell and expressed uncertainty about whether the call lights in their room and bathroom worked. This resident reported having to wait longer for staff assistance and sometimes asked staff to leave the bathroom door open so they could call for help verbally. A third resident, who had a tracheostomy and communicated by typing on a cell phone, also used a hotel-like bell and reported delays in receiving assistance after calling for help. Staff interviews revealed that the call light system was dependent on a wireless network, which frequently lost signal, and that pagers, which were part of the system, were not consistently used or functional. The call light alert box at the nursing alcove displayed incorrect dates and times, and staff were unable to determine how long it took to respond to calls or if someone else had turned off the alert. Maintenance staff confirmed that the system was not hard-wired, was reliant on WiFi, and that no regular audits were conducted to ensure functionality; instead, they responded only to complaints. Facility policy required that call lights be accessible and functional at each resident's bedside, toilet, and bathing facility, and that staff be educated on their use. However, observations and interviews indicated that the system did not consistently alert staff, alternative bells were not effective, and staff were not always aware of or using all components of the system. Documentation from the system manufacturer recommended monthly testing of personal help buttons, but maintenance staff did not perform routine checks. The deficiency was further evidenced by the lack of hallway or in-room call light indicators and the facility's reliance on resident complaints to identify issues.
Failure to Maintain Consistent Dialysis Documentation
Penalty
Summary
The facility failed to ensure consistent dialysis communication documentation and assessments were maintained in the clinical record for a resident who required dialysis services. The resident, who was readmitted with a diagnosis of end-stage renal disease, reported receiving dialysis care five days a week at the bedside. However, a review of the medical record revealed that the last documented dialysis communication/assessment was dated nearly a year prior. The Director of Nursing confirmed that the dialysis entity emails the documentation to the facility but acknowledged that the records had not been uploaded to the resident's medical record since May 2023. The deficiency was identified during an observation and interview with the resident, as well as a review of the medical record and an interview with the Director of Nursing.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to provide a privacy cover over an indwelling catheter bag for one resident (R2). On multiple occasions, R2 was observed without a dignity privacy bag covering the catheter bag. Specifically, on 4/22/24 at 9:31 AM and on 4/23/24 at 8:43 AM, R2 was seen in bed with the catheter bag exposed. The Director of Nursing (DON) confirmed on 4/24/24 at 1:09 PM that R2 should have had a dignity privacy bag and that nursing staff are responsible for ensuring these are in place. R2's medical record indicated diagnoses of Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, and the resident was cognitively intact with a Brief Interview of Mental Status score of 13/15. The facility's policy on promoting and maintaining resident dignity, revised in 11/2023, mandates maintaining resident privacy, which was not adhered to in this case.
Failure to Document Residents' Code Status and Treatment Preferences
Penalty
Summary
The facility failed to ensure that the code status and treatment preferences of three residents were clearly documented in their clinical records. Resident 46 had a signed advance directive indicating Do-Not-Resuscitate (DNR) status, but this was not flagged in the electronic medical record (EMR). The Director of Nursing (DON) and Social Worker provided conflicting information about the resident's code status, with discrepancies between the hard chart and the EMR. The Social Worker reported that the resident had changed their code status to full code upon readmission, but this was not accurately reflected in the records. Resident 48's clinical record did not have a code status flagged in the EMR, and no advance directive form was initially found in the EMR. The resident's social services assessment indicated a full code status, but this was not documented in the EMR. The facility later uploaded an advance directive form indicating the resident's wishes, but it was discovered that the form was only in the binder on the unit and not in the EMR prior to questioning. Resident 108's clinical record also lacked a flagged code status in the EMR and did not have an advance directive form indicating the resident's treatment wishes. The DON later uploaded an advance directive form into the EMR, which indicated the resident's full code status and other treatment preferences. The form was found in the binder on the unit but was not initially in the EMR. The facility's policy on residents' rights regarding treatment and advance directives was not followed, leading to inconsistencies in the documentation of residents' treatment preferences.
Failure to Develop and Implement Hearing Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with hearing loss. The resident was admitted with a diagnosis of hearing loss in the right ear and had hearing aids. Despite this, the resident's comprehensive care plan did not address hearing concerns or the use of hearing aids. The deficiency was identified during an interview with the MDS Coordinator, who acknowledged that the care plan for hearing concerns was missed and was only added to the EMR after it was overheard that the resident did not have a care plan for hearing aids. The Director of Nursing confirmed that the resident should have had a hearing care plan and that it was the MDS Coordinator's responsibility to create it.
Failure to Thoroughly Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and document a pressure ulcer for a resident with a traumatic brain injury and severely impaired cognition. The resident was dependent on staff for all activities of daily living, including bed mobility and transfers. Despite having an active physician's order for Venelex ointment to be applied to the coccyx, there was no documentation of wound care progress since 2020. The Medication Administration Records (MAR) indicated multiple instances of redness and open skin on the coccyx and buttocks from February to April 2024, but no measurements or characteristics of the wounds were documented. Interviews with the wound care coordinator and the Director of Nursing (DON) revealed that weekly skin assessments were supposed to be documented on the MAR, and any wounds were to be evaluated by a physician. However, both the wound care coordinator and the DON confirmed that there was no documented assessment of the resident's wounds. An observation on April 24, 2024, revealed bloody drainage and partial thickness skin loss on the resident's coccyx, contradicting the nurse practitioner's earlier documentation that the wound had resolved. The nurse practitioner had documented the presence of a Stage IV sacral and ischial ulcer with minor bleeding in January and February 2024, but later notes in March and April 2024 indicated that the wound had resolved. Despite this, the observation on April 24, 2024, showed open areas and bloody drainage, indicating a lack of accurate and timely documentation. The facility's policy on skin assessment required detailed documentation of wound characteristics, which was not followed in this case.
Failure to Document Urinary Output for Resident with External Catheter
Penalty
Summary
The facility failed to document urinary output consistently for a resident with an external catheter. The resident, who had medical diagnoses including Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, required maximal assistance with bed mobility, toileting hygiene, and transfers. The resident's care plan specified that urine odor, color, amount, and sediment should be monitored and documented every shift. However, a review of the Treatment Administration Record (TAR) for January, February, and March 2024 revealed multiple instances where urinary output was not documented for both day and night shifts. The Director of Nursing (DON) confirmed that nursing staff are required to record the output when the Foley catheter is emptied. Despite this requirement, there were numerous undocumented outputs across several days in January, February, and March 2024. No facility policy was provided that addressed the documentation of urinary catheter output, indicating a lapse in adherence to the resident's care plan and proper documentation practices.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. According to the CDC's guidelines, antibiotic stewardship is crucial to optimize infection treatment and reduce adverse events. However, the facility's Infection Surveillance program from June 2023 through April 2024 showed multiple instances of 'N/A' documentation under criteria met for residents admitted from the hospital on antibiotics, indicating a lack of proper review and adherence to protocols. For Resident 159, the medical records revealed that the resident was prescribed Amoxicillin and Doxycycline for a productive cough associated with COVID-19, despite no documented justification for the antibiotics. The resident's progress notes indicated stable vital signs and no respiratory distress, yet antibiotics were administered from January 8th to January 15th, 2024. Similarly, Resident 160 was prescribed Cipro for a urinary tract infection based on symptoms like nausea and a positive dipstick test. However, the urine culture showed no growth, and the symptoms did not meet the criteria for a UTI, indicating inappropriate antibiotic use. Interviews with the facility's Infection Control Preventionist (ICP) revealed that the facility did not review antibiotics prescribed at the hospital, leading to 'N/A' documentation. The ICP could not provide an explanation or documentation for the antibiotic administration for Resident 159 and only provided a physician's note and culture results for Resident 160. This lack of proper review and documentation highlights the facility's failure to adhere to antibiotic stewardship protocols, potentially affecting multiple residents prescribed antibiotics during their inpatient care.
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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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