Marvin & Betty Danto Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bloomfield, Michigan.
- Location
- 6800 West Maple, West Bloomfield, Michigan 48322
- CMS Provider Number
- 235288
- Inspections on file
- 26
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marvin & Betty Danto Health Care Center during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in shared shower and rehabilitation areas, including sewage odors, uncovered drains, dirty equipment, soiled linens on floors, and improper storage of personal care products. Facility leadership acknowledged the presence of these issues, which affected the cleanliness and safety of areas used by residents and staff.
A resident with no cognitive impairment reported that their personal belongings were searched by the NHA without consent after staff suspected them of hoarding and selling prescribed Oxycodone. The resident noticed their paperwork was disturbed and felt compelled to purchase a safe due to loss of trust. The NHA confirmed the search was conducted based on a rumor and without consent, in violation of facility policy guaranteeing privacy and confidentiality.
A resident with vascular dementia who required staff assistance for dressing and transfers waited approximately one hour and 45 minutes to be dressed and transferred out of bed after requesting help. Staff cited the need for two people for a mechanical lift and unavailability of the assigned CNA as reasons for the delay, despite other staff being available to assist. The DON confirmed the wait time was excessive.
A resident with vascular dementia and an indwelling catheter developed a new skin impairment on the right thigh that was not promptly identified or assessed, and no clear interventions were implemented to prevent recurrence. Staff were uncertain about the cause, and documentation did not show timely notification of a medical provider or effective preventive actions, despite facility policy requiring daily skin inspections and ongoing review.
A resident dependent on staff for mobility and skin care developed a deep tissue injury to the heel after inconsistent repositioning, incomplete skin assessments, and lack of documentation regarding the use of pressure-relieving boots. Staff did not consistently perform or document required interventions, and the wound was not identified until weeks after admission.
The facility failed to maintain a clean and homelike environment, with observations of dirty and cluttered rooms, inconsistent housekeeping, and inadequate laundry services. Residents reported issues with obtaining clean linens and towels, and the facility's maintenance practices were found lacking, with unreported repairs and improper use of extension cords for medical devices.
The facility failed to properly administer and document medications for two residents, leading to complaints of delayed pain relief and inaccurate records. One resident did not have their as-needed narcotic pain medication documented on the MAR, while another resident's medication administration was not recorded at all. The DON confirmed that medications should be documented at the time of administration, as per policy.
A resident with multiple health conditions did not receive Hospice services as per the plan of care, which required skilled nursing and nurse aide visits twice a week. The facility's DON was unaware of the oversight, and the facility's policy on Hospice service coordination was not followed.
The facility failed to ensure proper storage and security of medications across multiple medication carts. Medications were found unpackaged and without patient identifiers, and a medication cart was observed unlocked and unattended. The Director of Nursing acknowledged the issue, which violated the facility's medication storage policy.
A resident was found with medical ointments and treatments in their room without an order for self-administration. The facility's policy requires an order and secure storage of medications. The resident, moderately cognitively impaired, reported applying the medications themselves or with staff assistance. The medications were removed by staff after the deficiency was noted.
The facility failed to ensure accurate and timely implementation of advanced directives for two residents. One resident had conflicting documentation regarding their code status, with a signed DNR form and an electronic record indicating FULL CODE. Another resident's son, acting as DPOA, made medical decisions without proper authorization, as the resident was cognitively intact and not deemed incompetent. The facility's policy requires prompt documentation and discussions regarding health status and treatment options, which were not adequately followed.
A resident with a history of stroke and aphasia was unable to effectively communicate their needs due to the facility's failure to provide alternative communication methods. Despite being non-verbal and expressing distress with their modified diet, the resident had no access to communication boards or assistive devices. Staff confirmed the communication challenges, and the facility lacked a policy to address these needs, leading to the resident's ongoing frustration.
A resident with multiple diagnoses was observed receiving two liters of oxygen via nasal cannula without a physician's order, as required by the facility's policy. The DON confirmed the absence of the necessary order, highlighting a failure in ensuring proper documentation for oxygen therapy.
A facility failed to provide trauma-informed care for a resident with PTSD, depression, and anxiety. The resident struggled to adjust to the LTC setting and was dissatisfied with their psychological provider. Despite requests for a different provider and additional support, no changes were made. The care plan lacked specific interventions for PTSD, and no triggers were identified. Staff were unaware of the PTSD diagnosis, affecting their ability to provide appropriate support.
A resident in an LTC facility experienced three medication errors, resulting in a 7.32% error rate. An LPN inaccurately measured MiraLAX, administered Metoprolol against ordered parameters, and failed to administer Flonase as documented. The DON acknowledged these errors.
A facility failed to maintain resident dignity and respect when a CNA entered rooms without knocking or announcing themselves, addressing a resident in a gruff tone. The CNA acknowledged the oversight, citing numerous call lights as a distraction. The DON confirmed awareness of the issue.
A resident with multiple skin issues, including an open wound on the sacrum and a blister on the right heel, experienced delayed and conflicting wound care interventions. Despite being identified on admission, appropriate treatment for the right heel was delayed, and there was no physician assessment of the wounds until weeks later. The facility's DON acknowledged the concerns and indicated a review of the medical record for assessments.
A resident was found with their feet and legs tied in a knot with blankets, indicating a failure to ensure freedom from physical restraints. Staff members observed the resident in this condition, but the facility's response was inconsistent, with discrepancies in staff accounts and a lack of proper investigation. The facility suggested the resident tied themselves, despite evidence to the contrary, and failed to provide a restraint policy when requested.
A resident with dementia and other health issues was found with blankets tied around their legs, suggesting possible abuse. Despite observations by staff, the incident was not reported as an abuse allegation to the appropriate authorities. The facility's investigation was inadequate, and the Administrator dismissed the incident as a rumor, failing to comply with reporting guidelines.
Failure to Maintain Sanitary Conditions in Common and Rehabilitation Areas
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's residential common areas, including a shared shower room, tub room, and rehabilitation area. In the shared shower area, there was a strong sewage odor, an uncovered floor drain, exposed sharp metal fasteners, broken tiles with debris, and a dirty tub with a thick brown ring. The tub room was being used for storage, containing a bedside commode and floor mat, and the shower bed had cracked foam padding with visible black hairs. Both shower rooms contained used wet towels and washcloths on the floor, with puddled water, soap residue, and additional black hairs present. The private toilet room was found locked, restricting access for residents. A Hoyer lift was observed with food crumbs on its base, and both the DON and NHA acknowledged the unsanitary conditions upon inspection. In the rehabilitation area, the training bathroom was found to have opened, partially used peri care spray bottles, a container of multiuse sanitation wipes, and an unidentified blue liquid stored on the toilet tank. The perimeter of the rehab area had dusty, dirty floors and equipment stored on the floor, with dead plant debris on the windowsill and floor. The Director of Rehab Services confirmed the unsanitary storage of supplies and the need for cleaning. These conditions were directly observed and acknowledged by facility leadership, indicating a failure to maintain a sanitary healthcare environment in areas used by residents and staff.
Failure to Obtain Consent Before Searching Resident's Personal Belongings
Penalty
Summary
The facility failed to obtain consent before searching a resident's personal belongings. A resident, who was cognitively intact as indicated by a perfect BIMS score, reported that after staff suspected them of hoarding and possibly selling their prescribed Oxycodone, the Nursing Home Administrator (NHA) searched their room and personal items without seeking or obtaining the resident's consent. The resident noticed their personal paperwork had been disturbed and subsequently felt compelled to purchase a safe due to a loss of trust in the facility. The NHA later confirmed during an interview that the search was conducted based on a rumor and without the resident's consent, and could not provide further justification for not involving local authorities if illegal activity was suspected. Facility policy reviewed during the investigation stated that residents are guaranteed rights to privacy and confidentiality under federal and state law. Despite this, the NHA and DON acknowledged that only verbal consent is typically obtained for room searches, and in this case, no consent was obtained at all. The incident was triggered by staff suspicion and a rumor, rather than direct evidence or proper procedure, resulting in a violation of the resident's rights to privacy and dignity.
Delay in Assistance with Activities of Daily Living
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for dressing and transfers requested assistance to get dressed and out of bed. The resident, who had vascular dementia and moderately impaired cognition, expressed her desire to choose her own outfit and notified a CNA of her request. Despite this, the resident remained in bed wearing a hospital gown for approximately one hour and 45 minutes after her initial request. During this period, staff interactions included a CNA changing her brief and putting on pants, and another CNA indicating that assistance was delayed due to the need for two staff members for a mechanical lift transfer and the other CNA being occupied with another resident. The resident's care plan specified the need for assistance with dressing and a mechanical lift with two staff for transfers. Observations confirmed that the resident was not assisted in a timely manner, as she remained in bed for an extended period after her request. The DON acknowledged that the wait time was excessive and noted that additional staff, including nurses and managers, could have assisted with the transfer. The delay in providing assistance was directly observed and confirmed through staff interviews.
Failure to Promptly Identify and Address New Skin Impairment
Penalty
Summary
A deficiency occurred when staff failed to promptly identify and implement interventions for a new skin impairment in a resident with vascular dementia, who was at risk for pressure ulcers and required substantial assistance with mobility. The resident was observed with an indwelling urinary catheter and a black area on the right lateral thigh, which was first noted as a skin tear by staff on 3/20/25. Documentation showed that a daily body audit was in place, and the new wound was recorded on 3/20/25. However, the wound was not assessed by the wound nurse until the following day, and there was no documentation that a medical provider was notified at the time of discovery. The wound was described as a blister, but photos indicated a flat black area rather than a fluid-filled lesion. Interviews with the wound nurse and DON revealed uncertainty about the cause of the wound, with possible explanations including friction from a wheelchair or mechanical lift. The DON stated that no specific interventions were implemented to prevent recurrence, and the facility's skin management policy required daily skin inspections and ongoing review of interventions for effectiveness. The lack of timely identification, assessment, and implementation of preventive measures contributed to the deficiency.
Failure to Prevent Pressure Ulcer and Ensure Accurate Skin Assessments
Penalty
Summary
A resident with a history of joint replacement surgery, macular degeneration, and a right shoulder rotator cuff tear was admitted to the facility and was dependent on staff for activities of daily living. The resident was care planned to require extensive assistance for bed mobility and to have pressure-relieving boots applied while in bed, as well as to be turned and repositioned every two hours. Despite these interventions, documentation revealed inconsistent completion of required skin assessments and repositioning, with multiple days lacking evidence that these tasks were performed, particularly on the midnight shift. The resident developed a deep tissue injury (DTI) to the left heel, which was not identified until more than two weeks after admission. Initial skin assessments and daily body audits failed to document any issues with the left heel, and the majority of daily skilled assessments inaccurately reported no skin issues, despite the resident having both a surgical wound and a sacral pressure injury requiring daily treatment. Staff interviews indicated that the resident did not routinely wear the prescribed foam boots prior to the development of the wound, and there was no documentation of refusal or non-compliance until after the DTI was identified. Further, the resident reported difficulty repositioning themselves and stated that staff only assisted with turning when asked, with particular difficulty obtaining assistance at night. The facility's policy required daily skin inspections and accurate documentation, but these were not consistently followed. The Director of Nursing acknowledged gaps in both the frequency and accuracy of skin assessments and agreed that refusals of interventions such as heel boots should have been documented.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. During a survey, several rooms were found in disarray, with dried tube feeding formula on equipment, missing paint, and gouged drywall. Floors were littered with food debris, dirty clothing, and trash, and some rooms had open garbage bags containing linens and clothing. Residents reported inconsistent housekeeping services, particularly on weekends, and expressed dissatisfaction with the cleanliness of their living spaces. Residents also raised concerns about the facility's laundry services. They reported issues with obtaining clean linens and towels, with some staff allegedly hoarding these items, making them difficult to access. The change in the laundry process, which involved placing dirty laundry in plastic bags without proper labeling, led to residents not receiving their clothes back. Additionally, the mixing of dirty linens with clothing was noted as a potential infection control issue. The facility's laundry staff struggled to manage the workload, resulting in delays in returning clean laundry to residents. The facility's maintenance practices were also found lacking. A nebulizer was improperly plugged into an extension cord, and large gouges in the walls of some rooms had not been reported or repaired. The maintenance director was unaware of these issues, indicating a failure in the facility's reporting system for needed repairs. The laundry room was observed to have collected dust and clean linen racks exposed to potential contaminants. These deficiencies highlight the facility's failure to provide a safe and homelike environment for its residents.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to ensure medications were administered and documented according to professional standards for two residents, resulting in complaints of delayed pain medication and inaccurate medical records. Resident 47, who has intact cognition and medical conditions including heart failure, diabetes, and chronic kidney disease, reported delays in receiving as-needed narcotic pain medication. A review of the CONTROLLED SUBSTANCE RECORD and Medication Administration Record (MAR) revealed multiple instances where oxycodone was signed out but not documented on the MAR. Nurse 'A' admitted to not documenting the administrations on the MAR, relying instead on the CONTROLLED SUBSTANCE RECORD for timing and administration. Resident 104, with diagnoses including hypertension, heart failure, and prostate cancer, was observed receiving medications from LPN A, but the administration was not documented on the MAR. Despite multiple attempts to reconcile the MAR, no documentation was found for the medications administered to Resident 104. The Director of Nursing confirmed that medications should be documented at the time they are administered, as per the facility's policy. The lack of documentation for both residents indicates a failure to adhere to the facility's medication administration policy.
Failure to Provide Hospice Services Per Plan of Care
Penalty
Summary
The facility failed to ensure that Hospice services were provided according to the plan of care for a resident who was under Hospice care. The resident, who had multiple diagnoses including multiple sclerosis, pressure ulcers, osteomyelitis, anxiety disorder, dementia, and contractures, was supposed to receive skilled nursing visits twice a week and nurse aide visits twice a week as per the Hospice plan of care. However, the review of hospice staff notes revealed that the first skilled nursing visit occurred two weeks after the resident signed on for services, and subsequent visits did not meet the twice-weekly requirement. Additionally, there were no documented visits from a Hospice nurse aide. During an interview, the facility's Director of Nursing (DON) was unaware of who was responsible for ensuring that the Hospice company conducted visits per the plan of care. The DON initially believed the resident was to receive skilled nursing visits once a week and nurse aide visits twice a week, but upon reviewing the Hospice plan of care, it was confirmed that the services had not been provided as outlined. The facility's policy requires that Hospice providers have a written agreement with the facility and are responsible for meeting professional standards and timeliness of service, which was not adhered to in this case.
Improper Medication Storage and Security
Penalty
Summary
The facility failed to ensure proper storage of medications across four medication carts, as observed on January 8, 2024. During the inspection, various medications were found unpackaged and without patient identifiers in the 700-1, 600, and 500 medication carts. Specific medications, such as white round tablets, peach round EP102, and insulin pens, were noted to be improperly stored. Additionally, an insulin pen was labeled only with a room number, lacking a patient identifier. The Director of Nursing acknowledged that medications should not be stored without secured packaging and patient identifiers. Furthermore, on January 7, 2024, a medication cart located next to a resident's room was observed to be unlocked and unattended. A nurse, identified as Nurse S, was seen coming from a resident's room and confirmed that the cart should have been locked. The facility's policy on medication storage, dated April 2019, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, in the packaging or containers in which they are received. The observations indicate a failure to adhere to this policy, leading to the deficiency.
Failure to Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain an assessment and physician's order for a resident to self-administer medications. During an observation, a resident was found with several medical ointments and treatments on their shelf and tray table. The resident, who was alert and able to answer questions, reported that they could apply some of the medications themselves or have staff assist them. However, it was noted that the resident did not have an order to self-administer medications, and the medications were not secured as required by the facility's policy. Further investigation revealed that the medications should not have been left in open areas in the resident's room. The nurse assigned to the hall confirmed the lack of an order for self-administration and removed the medications. The Unit Manager and the Director of Nursing both confirmed that the facility's policy requires an order for self-administration and that medications should be locked up when not in use. The resident's clinical record showed a moderate cognitive impairment, with a BIMS score of 11/15, and diagnoses including cerebral infarction and type II diabetes.
Failure to Implement and Document Advanced Directives
Penalty
Summary
The facility failed to ensure timely and accurate advanced directives information was in place and implemented for two residents, R66 and R2. R66 was observed to be severely cognitively impaired and had conflicting documentation regarding their code status. The electronic face sheet indicated R66 was a FULL CODE, while an Advance Directives form signed by the resident and a legal representative indicated a Do Not Resuscitate (DNR) status. Social Worker F, assigned to R66, claimed the resident had changed their wishes to FULL CODE, but no supporting documentation was provided. Additionally, a hospital record indicated the resident did not want CPR or intubation, further complicating the situation. R2, who was cognitively intact, was noted as a FULL CODE in their clinical record. However, their son, who was activated as the Durable Power of Attorney (DPOA), was making medical decisions without the resident being deemed incompetent. The DPOA document did not authorize the son to make decisions regarding code status or medical treatments, yet consent forms for medications and infection control were signed by the son. Social Worker F acknowledged the unusual nature of the DPOA but did not ensure proper documentation or discussions regarding R2's end-of-life wishes. The facility's policy on Advance Directives/Advance Care Planning requires that advance directives be respected and documented promptly in the medical record. The policy also mandates that the attending physician provide information to the resident and legal representative regarding health status and treatment options. The discrepancies in the documentation and lack of proper discussions with the residents or their legal representatives led to the deficiencies identified in the survey.
Failure to Provide Communication Aids for Non-Verbal Resident
Penalty
Summary
The facility failed to assess and provide alternative or augmentative communication methods for a resident with significant communication challenges due to medical conditions. The resident, who had a history of stroke, aphasia, hemiplegia, seizure disorder, and depression, was observed to be non-verbal and unable to effectively communicate their needs. Despite being able to eat independently, the resident expressed distress and frustration with their modified diet and had difficulty communicating their needs to staff. During observations, the resident used gestures to indicate dissatisfaction with their meal and pointed to a sore in their mouth, indicating pain. The resident also pointed to their clenched right hand and foot, suggesting a need for assistance with a hand splint and foot brace. However, there were no communication boards or assistive devices available in the resident's room to facilitate communication. Staff members confirmed the resident's communication challenges and acknowledged the absence of tools to aid in communication. The facility's failure to provide appropriate communication aids was further highlighted by the lack of a communication policy and the absence of speech therapy addressing communication needs. Although the resident had been evaluated for dysphagia, their communication needs were not initially addressed. The resident's care plan noted their non-verbal status but did not include alternative communication methods. This deficiency in providing necessary communication support led to the resident's ongoing frustration and inability to fully express their needs.
Lack of Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician's order for supplemental oxygen for a resident who was observed receiving oxygen therapy. On multiple occasions, the resident was seen in their wheelchair and bed with two liters of oxygen being delivered via nasal cannula from an oxygen concentrator. Despite the ongoing administration of oxygen, a review of the resident's clinical records revealed no physician's order for supplemental oxygen. The resident, who has diagnoses including spastic hemiplegic cerebral palsy, adjustment disorder, dysphagia, high blood pressure, and chronic pain, was unable to communicate verbally during an attempted interview. The Director of Nursing confirmed that there should have been an order for the supplemental oxygen, as per the facility's policy on oxygen administration, which requires verification of a physician's order for the procedure.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate trauma-informed care for a resident diagnosed with PTSD, depression, and anxiety. The resident, who was cognitively intact, expressed difficulty adjusting to the long-term care setting and dissatisfaction with their current psychological provider. Despite the resident's requests for a different provider and additional social services support, no changes were made. The resident's care plan lacked specific interventions for PTSD, and no triggers were identified or addressed. The resident's medical records indicated a history of trauma, including night terrors and past family abuse, yet the facility did not conduct a formal trauma assessment or provide supportive visits from social services. The social worker assigned to the resident was unaware of the PTSD diagnosis and acknowledged the lack of supportive visits and care planning. The facility's policy on trauma-informed care was not followed, as there was no individualized care plan addressing the resident's past trauma or identifying potential triggers. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis and care needs. The social worker and activity director were not informed of the diagnosis, which affected their ability to provide appropriate support and activities. The facility's failure to implement trauma-informed care and address the resident's psychosocial needs resulted in ongoing distress and care refusals by the resident.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.32% during a medication administration observation. This deficiency was identified when three medication errors were noted for one resident, R104, out of 41 opportunities. R104, who was admitted with medical conditions including hypertension, heart failure, prostate cancer, thyroid disorder, and renal insufficiency, was observed to have received an incorrect dose of MiraLAX due to inaccurate measurement by LPN A. Additionally, LPN A administered Metoprolol to R104 despite the resident's heart rate being below the ordered parameter of 60 beats per minute, with a documented heart rate of 57 beats per minute. Furthermore, during the medication administration observation, it was documented that R104 was given Flonase, an allergy relief medication, but it was not actually administered. The Director of Nursing was informed of these findings and acknowledged the errors, including the incorrect measurement of MiraLAX, the failure to adhere to Metoprolol administration parameters, and the discrepancy in the documentation and administration of Flonase. These actions and inactions led to the identified deficiency in medication administration practices at the facility.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of residents R805, R806, and R807, as observed during a survey. On the morning of November 19, 2024, call lights were activated and sounding at the nursing desk for the rooms occupied by these residents. Certified Nursing Assistant (CNA 'A') was observed entering the room of residents R806 and R807 without knocking or announcing themselves, and addressed R807 in a gruff, rushed tone. Additionally, CNA 'A' entered R805's room without knocking or announcing themselves, despite not being assigned to that resident. During an interview, CNA 'A' acknowledged the oversight but attributed it to the overwhelming number of call lights ringing. The Director of Nursing (DON) confirmed being informed of the dignity concerns by Unit Manager 'B' and acknowledged that such actions should not have occurred. These observations and interviews highlight the facility's failure to provide an environment that promotes and enhances residents' dignity, as required by regulations.
Failure to Implement Timely Wound Care Interventions
Penalty
Summary
The facility failed to timely implement effective wound interventions and ensure physician follow-up, assessment, and monitoring of a worsening wound for a resident identified as R502. Upon admission, R502 had several skin issues, including an open wound on the sacrum and an open blister on the right heel. Despite these conditions being identified on admission, there was a delay in implementing appropriate treatment for the right heel, which was not addressed until six days later. Additionally, there were conflicting treatment orders for the sacral area, with no clarification or explanation provided in the medical record. The medical record review revealed that multiple treatments were prescribed by medical doctors and nurse practitioners for R502's wounds, but there was no evidence of assessment or documentation of these wounds by the physician team until more than three weeks after admission. The first documented assessment of the resident's heels by the physician team occurred on 5/29/24, and the sacral wound was not acknowledged until 6/2/24. Furthermore, there was no documentation of the resident's noncompliance with turning and positioning, despite it being mentioned in a physician's note. The facility's Director of Nursing (DON) acknowledged the concerns regarding the sacral and right heel skin impairments and the delayed implementation of treatment. The DON indicated that the nursing staff and interdisciplinary team were following the resident's wounds but would review the medical record for physician/nurse practitioner assessments. The report highlights the lack of timely and effective wound care interventions and inadequate physician follow-up, which contributed to the worsening of the resident's pressure ulcers.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a resident, identified as R503, who was found with their feet and legs tied in a knot with blankets. The incident was reported to have occurred on the afternoon shift, and multiple staff members, including a Certified Nurse Aide (CNA) and a nurse, observed the resident in this condition. The resident, who had a history of dementia and was receiving hospice services, was unable to respond appropriately during an attempted interview. The clinical record review did not indicate any behavior consistent with self-restraining, contrary to the facility's suggestion that the resident might have tied themselves. Interviews with staff members revealed discrepancies in the facility's response to the incident. CNA 'G' reported finding the resident with their legs bound and expressed doubt that the resident could have tied the blankets themselves. Nurse 'H' confirmed the observation and attempted to identify the responsible party among the staff, but no one admitted to restraining the resident. Unit Manager 'I' was informed of the situation but claimed to have only been told that the resident was tangled in blankets, not tied. Despite reports of an in-service education on restraints, the Unit Manager did not provide such training at the time of the incident. The Director of Nursing (DON) and the facility's Administrator were also involved in the aftermath of the incident. The DON was not fully aware of the details and relied on the Unit Manager's account, which downplayed the severity of the situation. The Administrator conducted an investigation but concluded that the resident had tied themselves, despite evidence to the contrary. The facility failed to provide a restraint policy when requested, further indicating a lack of proper procedures and documentation regarding the use of restraints.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged abuse incident involving a resident, identified as R503, to the abuse coordinator and the State Agency. The incident involved R503 being found with blankets tied around their legs, which was initially observed by a Certified Nurse Aide (CNA) and a nurse. Despite the observations, the incident was not reported as an allegation of abuse to the appropriate authorities in a timely manner. R503, a resident with diagnoses including moderate protein calorie malnutrition, heart disease, adjustment disorder with anxiety, falls, and dementia, was receiving hospice services at the time of the incident. On the day of the alleged incident, a CNA found R503 with their legs bound by blankets, which they believed the resident could not have done themselves. The nurse on duty confirmed the observation and reported it to the Unit Manager, who did not take immediate action to report the incident as abuse. The facility's investigation into the incident was inadequate, as it was based on the assumption that R503 had tied the blankets themselves, despite evidence suggesting otherwise. The Administrator, who was also the Abuse Coordinator, did not consider the incident as an allegation of abuse, labeling it as a rumor instead. This led to a failure in reporting the incident to the State Agency as required by the facility's abuse and neglect procedural guidelines.
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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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