Maple Woods Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Clio, Michigan.
- Location
- 13137 North Clio Road, Clio, Michigan 48420
- CMS Provider Number
- 235518
- Inspections on file
- 21
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Maple Woods Manor during CMS and state inspections, most recent first.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident who was fully dependent and non-ambulatory exhibited increased pain and abnormal behaviors over several days, which were observed and reported by multiple CNAs to nursing staff. Despite these reports and visible signs such as an externally rotated leg, nursing staff did not conduct or document a thorough assessment, and no timely pain management was provided. The resident was only sent to the hospital after family intervention, where bilateral femoral neck fractures were discovered. The facility lacked a pain management policy and did not follow its change in condition notification policy, resulting in delayed recognition and treatment.
The facility failed to maintain appropriate hot water temperatures and chlorine levels, crucial for preventing Legionella growth. Despite policies for daily temperature checks, records showed inconsistent monitoring, with many readings below recommended levels. Maintenance staff acknowledged issues with a mixing valve and inconsistent temperature checks, creating potential risks for residents.
The facility failed to document and make accessible the code status of six residents, leading to potential miscommunication of treatment preferences. For one resident, the EMR lacked clear code status information, and the care plan did not reflect their wishes. Similar issues were found for other residents, with staff relying on a cumbersome binder system not part of the official medical record. The facility's policy did not ensure easy access to code status information.
The facility failed to conduct timely assessments and maintenance checks for enabler bars for several residents, leading to a deficiency in care. A resident had enabler bars without a care plan, and maintenance logs were incomplete. Another resident's assessments were delayed, and maintenance documentation was unclear. A third resident had no follow-up assessments after the initial one. The facility's policy required quarterly evaluations, which were not followed, indicating a systemic issue.
A facility failed to include a resident and his representative in the care planning process. Despite the resident having full cognitive abilities, he was not involved in any care planning meetings, and his wife, who is his representative, was not asked to participate in a care conference. The Clinical Care Coordinator confirmed that no interdisciplinary team members were present during the meeting with the wife, and there was no documentation of the meetings. This oversight contradicts the facility's policy on collaborative care planning.
The facility failed to update care plans for two residents, one with a suspected deep tissue injury and another with significant weight loss. The care plans did not reflect the current conditions or interventions, leading to deficiencies in care management.
A resident with multiple diagnoses, including paraplegia and heart failure, was observed with a hand brace provided by her daughter, but the facility failed to document, assess, or monitor its use. Despite an order for the brace, there was no documentation in the EMR, MAR, TAR, or care plans, and staff interviews confirmed the absence of a restorative nursing department. This lack of documentation and monitoring constitutes a deficiency in care.
A resident experienced new visual hallucinations and delusions, reporting seeing cats and rats in her room. Despite these symptoms being noted by staff on multiple occasions, the facility failed to act promptly, with no immediate assessment or monitoring conducted. The issue was only addressed during a survey process, highlighting a deficiency in the facility's response to the resident's change in mental status.
A facility failed to prevent a pressure ulcer for a resident and ensure timely skin assessments for another. One resident's pressure ulcer worsened due to a delay in replacing a worn wheelchair cushion, while another resident's skin issues were not promptly identified due to missed assessments. The facility did not adhere to its skin care protocols, contributing to these deficiencies.
A resident's enteral nutrition was administered at an incorrect rate, contrary to physician orders, and the DPOA was not informed of the change. Additionally, there were no documented orders for the routine care of the resident's PEG tube site. The facility's policy on resolving discrepancies before medication administration was not followed.
A facility failed to follow policies for skin and wound assessments, resulting in pressure ulcers in three residents. One resident developed a Stage III ulcer and multiple deep tissue injuries due to inconsistent repositioning and lack of documentation. Another resident developed Stage II and IV ulcers, with inadequate care plans and infection control breaches during dressing changes. A third resident's skin assessments were not conducted regularly. The facility's policies for weekly assessments and documentation were not followed, leading to these deficiencies.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Document Change in Condition Resulting in Delayed Pain Treatment
Penalty
Summary
A deficiency occurred when staff failed to promptly assess and document a change in condition for a fully dependent, non-ambulatory resident with multiple comorbidities, including dementia, schizoaffective disorder, and heart failure. The resident exhibited increased pain and abnormal behaviors, such as intense rocking, grimacing, and vocalizations, which were observed by several CNAs and reported to nursing staff. Despite these observations, nursing staff attributed the behaviors to the resident's baseline diagnoses and did not conduct or document a thorough assessment or follow-up, even when the resident's leg was noted to be externally rotated and he displayed pain upon touch. Multiple staff members, including CNAs and nurses, reported noticing the resident's increased discomfort and abnormal leg positioning over several days. These changes were communicated during shift reports and to the responsible nurse, but no progress notes or assessments were completed to address the resident's change in condition. Pain assessments documented a score of zero on the day the leg abnormality was discovered, and pain medication was administered only twice in the days preceding the event. The resident's family member ultimately insisted on hospital transfer, where imaging revealed acute, complete bilateral femoral neck fractures. The facility's investigation did not identify abuse or neglect but concluded that the injuries were likely subacute and possibly pathological in nature. However, the lack of timely assessment, documentation, and communication with the medical director regarding the resident's increased pain and change in condition resulted in a delay in treatment and recognition of the fractures. The facility did not have a specific pain management policy, and staff failed to follow the existing policy for change in resident condition, which required physician and family notification for significant changes.
Failure to Maintain Safe Water Temperatures and Chlorine Levels
Penalty
Summary
The facility failed to monitor and respond to abnormally low hot water temperatures, which is crucial for the prevention and management of Legionella. The Infection Prevention and Control (IPC) Nurses and the Maintenance Director were responsible for reviewing the water management program and monitoring water for Legionella. However, there was a lack of communication and awareness about any issues with the water system, as the IPC Nurse was not informed of any problems. The water management program book showed outdated testing, with the last test conducted in 2023, and the Administrator provided conflicting information about the testing dates. The facility's water testing results indicated that the chlorine levels in certain areas were significantly below the required minimum, and the hot water temperatures were not maintained at the recommended levels. The Corporate Maintenance Director acknowledged that the water temperatures were often below 110 degrees Fahrenheit, which is below the recommended range of 114-118 degrees Fahrenheit due to low chlorine levels. Despite the facility's policy to test water temperatures daily, there were many days without recorded temperatures, and the facility did not consistently test on weekends. The facility's water temperature records revealed numerous instances of temperatures below the recommended levels, with some readings even below 100 degrees Fahrenheit. Maintenance staff admitted to not taking daily temperature checks consistently and acknowledged issues with a mixing valve. The facility's failure to maintain appropriate water temperatures and chlorine levels, as well as the lack of consistent monitoring, created conditions conducive to the growth of Legionella, posing a potential risk to the residents.
Deficiency in Documenting and Accessing Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of six residents was documented and accessible in their medical records, which could lead to miscommunication regarding their treatment preferences. For Resident #12, the electronic medical record (EMR) did not clearly indicate the resident's code status, and the physician's order only referred to a Preferred Treatment Option without specifying the details. Additionally, the care plan for Resident #12 did not mention the code status, and similar issues were found for Residents #21, #53, #79, and #158, where the EMR contained forms with options but lacked specific orders or care plans reflecting the residents' wishes. Resident #92, who had moderate cognitive loss and was receiving hospice services, also had no clear documentation of code status in the medical record. The Clinical Care Coordinator acknowledged the absence of specific orders or care plans for code status and mentioned that staff would need to search through the EMR or refer to a binder at the nurse's desk to find this information. However, the binder was not part of the official medical record, and the process of locating a resident's code status was cumbersome due to the binder's organization. During interviews, it was revealed that the binders containing code status information were difficult to navigate, and some documents, like the one for Resident #92, were of poor quality and unreadable. The facility's policy on Advanced Directives did not provide a clear process for ensuring that residents' code status was easily accessible in the medical record, contributing to the deficiency in maintaining accurate and accessible documentation of residents' treatment preferences.
Failure to Conduct Timely Assessments and Maintenance for Enabler Bars
Penalty
Summary
The facility failed to complete necessary assessments and maintenance checks for enabler bars for four residents, leading to a deficiency in care. Resident #2 was observed with bilateral enabler bars affixed to her bed, but her care plan did not include any information related to these bars. The maintenance logs for Resident #2 were incomplete, with no record of the initial four-day monitoring after installation. The Maintenance Director confirmed that the resident needed the enabler bars, but there was no documentation to support this need. Resident #71 had a care plan for assist rails to enhance mobility, but the quarterly assessments for the continued use of enabler bars were not completed on time. The last assessment was five months late. The maintenance logs were unclear, with an 'X' next to the room number, making it uncertain whether the enabler bars were inspected for safety and functionality. Similarly, Resident #76's assessments were not completed at the appropriate intervals, and the maintenance logs showed lines through the initial monitoring days, indicating a lack of clarity in the documentation. Resident #75 had an initial assessment for enabler bars, but no subsequent assessments were completed. The facility's policy required quarterly evaluations of residents' need for rails, which was not adhered to. The Clinical Care Coordinator acknowledged the responsibility of unit managers to ensure assessments were completed, but the last monthly audits of enabler bars were conducted months prior, indicating a systemic issue in maintaining compliance with the facility's policies.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to include and document the participation of a resident and his representative in the care planning process. The resident, who had been at the facility for nearly three weeks, was not involved in any care planning meetings. His wife, who is his representative, reported that she had not been asked to participate in a care conference or care planning meeting with the resident and the facility. The resident confirmed that he had not been included in any care planning meetings. The resident's medical history includes dementia, heart failure, kidney failure, an intestinal disorder, sepsis, a history of falls, rib fractures, and gait and mobility abnormalities. Despite having full cognitive abilities, as indicated by a BIMS score of 13/15, the resident was not involved in the care planning process. The Clinical Care Coordinator (CCC) responsible for conducting care conferences stated that a meeting was held with the resident's wife over the phone, but no other staff from the interdisciplinary team was present. The CCC also confirmed that the resident was not included in the meeting and that there was no documentation of the meetings with the resident or his wife. A review of the facility's policy on the care planning process emphasized the importance of a collaborative partnership with the interdisciplinary team, resident, and/or resident representative, and the need to provide an opportunity for the resident to participate in planning care and treatment changes. However, this policy was not followed in the case of this resident.
Failure to Update Care Plans for Skin and Nutrition
Penalty
Summary
The facility failed to timely revise and update care plans for two residents, resulting in care plans not reflecting the current status and needs of the residents. Resident #33, who has a history of dementia, major depressive disorder, chronic systolic heart failure, anxiety, and hypertension, was found to have a suspected deep tissue injury (SDTI) on her right heel and ankle. Despite this, the care plan for skin impairment had not been revised since February and did not mention the current skin conditions. The Unit Manager acknowledged that the care plan should have been updated to include a short-term care plan for the SDTI and the actual skin issue, but it was only revised after being notified of the oversight. Resident #63, with diagnoses including dementia, major depressive disorder, encephalopathy, and hypertension, experienced a significant weight loss of 17% over six months. Despite being started on supplement shakes to aid in weight gain, the care plan for nutrition had not been updated since 2021 and did not include a specific plan for addressing the weight loss. The Certified Dietary Manager admitted to not creating a specific care plan for weight loss, instead incorporating it into the general nutritional care plan. This lack of timely updates and specific care plans for the residents' changing conditions led to deficiencies in their care management.
Failure to Document and Monitor Hand Brace for Resident
Penalty
Summary
The facility failed to ensure proper documentation, assessment, and monitoring of a hand brace/splint for a resident who was reviewed for rehab and restorative services. The resident, who was observed with a splint/brace on her right hand, reported that her daughter had provided the brace and staff assisted her in putting it on and off. However, the resident did not perform any exercises for her right hand or arm. The resident's medical records, including the Face sheet, Minimum Data Set (MDS) assessment, and physician orders, indicated that she had multiple diagnoses, including paraplegia, heart failure, COPD, diabetes, and others. Despite an order allowing the use of a soft brace, there was no documentation of restorative services or assistance with the brace in the electronic medical record (EMR), Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plans. Interviews with facility staff, including the Therapy Director and Clinical Care Coordinator, revealed that the facility did not have a dedicated restorative nursing department, but nurse aides were trained to perform restorative functions. The Clinical Care Coordinator acknowledged the existence of an order for the brace but confirmed the absence of further documentation or a care plan related to the brace. The facility's policy on the Restorative Nursing Program emphasized evaluating residents individually to maintain their highest functional level, yet there was no evidence of such evaluation or documentation for the resident's hand brace. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.
Delayed Response to Resident's Change in Mental Status
Penalty
Summary
The facility failed to act timely on a change in mental status for Resident #11, who was observed experiencing visual hallucinations and delusions. On 4/9/2025, the resident reported seeing cats on her dresser, which she described as resembling wolves. This was a new onset for the resident, who had no prior history of delusions or visual hallucinations. Despite the resident's ability to communicate her needs and the presence of a major depressive disorder among her diagnoses, the facility did not address these symptoms promptly. The resident's hallucinations were first noted on 3/31/2025, when a CNA reported the resident talking about seeing live rats, but no immediate action was taken. The delay in addressing the resident's change in condition was further highlighted by the Nurse Practitioner's documentation on 4/1/2025, which noted the resident's confusion and visual hallucinations but did not result in further assessment or monitoring. It was not until the survey process on 4/9/2025 that the facility began to take steps to address the issue, including initiating a behavior log and planning a medical workup. This lack of timely intervention represents a deficiency in the facility's response to a significant change in the resident's mental status.
Failure to Prevent Pressure Ulcers and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for Resident #83 and ensure timely skin assessments for Resident #33. Resident #83, who was admitted with multiple diagnoses including a Stage 3 pressure ulcer, was observed to have a worsening condition of her pressure ulcer on the left buttock. Despite being reliant on staff for assistance with turning and repositioning, the facility did not replace her worn wheelchair cushion for over a month, which was a significant factor in the development and progression of her wound. The facility's care plan lacked proactive measures to prevent further skin breakdown, and interventions were only added after the wound had developed. Resident #33, who was admitted with conditions such as dementia and heart failure, had a suspected deep tissue injury on her right heel and ankle. The facility failed to conduct timely skin assessments, as there was a gap between assessments from March 14 to March 28, during which no skin assessment was completed. This oversight was acknowledged by the unit manager, who stated that skin assessments should have been conducted twice weekly in conjunction with shower days. The lack of timely skin assessments contributed to the failure to identify and address skin issues promptly. The facility's policy on skin risk assessment and treatment was not adequately followed, as evidenced by the lack of daily skin inspections and timely reporting of abnormal skin conditions. The deficiencies in both cases highlight a failure to adhere to established protocols for skin care and prevention, leading to the development and progression of pressure ulcers in the residents.
Failure to Follow Enteral Nutrition Orders and Notify DPOA
Penalty
Summary
The facility failed to adhere to a physician's order for enteral nutrition for Resident #95, who was observed with an incorrect infusion rate of 50 mL/hour instead of the prescribed 60 mL/hour. This discrepancy was noted on 4/8/2025, despite the physician's order being updated on 4/1/2025. The nurse responsible for Resident #95 was unaware of the change in the infusion rate, and the error was not corrected until later in the day when the rate was temporarily increased to compensate for the missed volume. Additionally, the facility did not notify Resident #95's Durable Power of Attorney (DPOA) about the change in the tube feed rate from 50 mL/hour to 60 mL/hour. The resident's daughters, who are frequently present at the facility, were not informed of this change or the temporary increase in the infusion rate to make up for the missed volume. This lack of communication with the resident's responsible party was confirmed by both the daughters and the Registered Dietitian. Furthermore, there were no documented orders for the routine cleansing, assessment, and monitoring of Resident #95's PEG tube site following her readmission on 3/21/2025. The Clinical Care Coordinator and Corporate Nurse confirmed the absence of such orders, which are essential for maintaining the site. The facility's policy on medication administration emphasizes resolving any discrepancies before proceeding, yet this was not adhered to in the case of Resident #95.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to operationalize policies and procedures for skin and wound assessments, leading to the development of pressure ulcers in three residents. Resident #1 developed a Stage III pressure ulcer on the coccyx and multiple suspected deep tissue injuries on the feet. The resident was severely cognitively impaired, dependent on staff for repositioning, and had a poor appetite. Despite being on a pressure-relieving mattress, there was a lack of documentation regarding repositioning and the application of protective boots. The care plans lacked specific interventions for each wound, and skin assessments were not conducted consistently. Resident #2 developed a Stage II pressure ulcer on the right buttock and a Stage IV pressure wound on the right ischium. The resident had moderately impaired cognition and was dependent on staff for mobility. The care plan did not include specific positioning guidelines, and wound assessments were not conducted regularly. During a dressing change, infection control protocols were not followed, as the nurse used the same 4x4 gauze to clean multiple wounds without changing gloves or performing hand hygiene. Resident #3's skin assessments were not completed consistently, with gaps of up to 14 days between assessments. The Director of Nursing acknowledged the lack of consistent documentation and indicated that the air mattress settings were incorrect. The facility's policy required weekly skin assessments and documentation of wound characteristics, but these were not adhered to, leading to the deficiencies observed.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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