Medilodge Of Frankenmuth
Inspection history, citations, penalties and survey trends for this long-term care facility in Frankenmuth, Michigan.
- Location
- 500 West Genesee, Frankenmuth, Michigan 48734
- CMS Provider Number
- 235175
- Inspections on file
- 27
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Medilodge Of Frankenmuth during CMS and state inspections, most recent first.
The facility failed to ensure dignity and privacy for residents during meal service and personal care. Two residents were left without meals while others were served, and a resident was exposed without clothing due to an open privacy curtain. Additionally, residents reported unmet needs and unresponsive staff regarding call lights. A resident's room had a persistent urine odor, and another resident was unable to reach their call light, highlighting issues in maintaining a dignified environment.
The facility failed to assess and obtain informed consent for the use of bed rails for several residents, leading to a deficiency. Observations showed residents using siderails without proper documentation or consent. Care plans did not address siderail use, and consent forms were incomplete. Staff interviews revealed a lack of awareness and compliance with the facility's policy on bed rails.
The facility failed to ensure proper labeling, storage, and discard of medications across four medication carts, leading to deficiencies in medication management. Observations revealed that multi-dose medications were not dated with either an open date or expiration date, and ampules were found outside of their foil packets. Interviews with staff confirmed the lack of adherence to medication labeling and storage policies, and the Nursing Home Administrator admitted to the absence of a multi-dose medication policy.
The facility failed to maintain sanitary conditions in the kitchen and did not follow proper thawing procedures for hamburger meat. Observations included equipment with dried food, improper thawing of meat in a pool of blood, and a small brush on the handwashing sink that could transfer bacteria. The facility's policies on food preparation and service were not adhered to, leading to potential cross-contamination issues.
The facility failed to ensure a clean environment for residents, with observations of dusty fans and improperly stored oxygen tubing. A resident with Guillain-Barre Syndrome had a dusty fan blowing on him, and another resident's oxygen tubing was not stored in a bag to prevent contamination. Additionally, a resident receiving respiratory treatments had a dusty fan and a urine catheter bag improperly placed. The facility lacked specific policies for cleaning fans and storing respiratory equipment.
The facility failed to update care plans for residents with changing needs, including those with a history of falls and specific code status preferences. Several residents were observed with siderails, but their care plans lacked documentation on their use and monitoring. The DON was unaware of the siderails, indicating a gap between policy and practice.
The facility failed to ensure accurate weight measurements for two residents, leading to incorrect documentation in their medical records. One resident was recorded to have gained 16 pounds in one day, which was later corrected to a 1.7-pound loss after reweighing. Another resident was documented with an implausible weight gain of 1,643.5 pounds in one day. These errors were not addressed until surveyor intervention, and the RD confirmed that weights were not routinely checked for accuracy.
The facility failed to ensure clean and dry storage of respiratory equipment for three residents, leading to unsanitary conditions. A resident's nebulizer mask was found uncovered on a nightstand, another's CPAP mask was stored improperly, and a third's treatment mask was not stored as expected. The IC Nurse and DON acknowledged the improper storage practices.
A facility failed to monitor and update the antibiotic line listing for a resident receiving Gentamycin through a suprapubic catheter. The medication was administered less frequently than prescribed, and the resident was omitted from infection control line listings. The RN Infection Control nurse was unaware of this omission and acknowledged the lack of monitoring since 2023, noting the treatment's ineffectiveness based on lab results.
A group of residents expressed dissatisfaction with the facility's evening snack provision, citing limited variety and insufficient quantities. Observations revealed that snack carts were not restocked regularly, and available items were repetitive, with minimal protein options. Dietary staff confirmed the limited stocking of snack carts and lack of kitchen access after hours, contributing to residents' frustration.
A resident in a LTC facility experienced poor skin conditions due to inadequate ADL care. Despite being cognitively intact, the resident reported delays in staff assistance after episodes of fecal incontinence, leading to sores on the buttocks. The resident's skin issues were attributed to frequent urinal spills and loose stools, as well as potential shearing from a Hoyer sling. The facility's ADL policy was not adequately followed, resulting in the deficiency.
The facility failed to provide timely and available physician-ordered medications for two residents. One resident, admitted with fractures and cancer, did not receive pain medications for 24 hours, leading them to leave the facility for relief. Another resident experienced a delay in receiving both pain and general medications, including Eliquis. The facility's policy did not address backup medication availability, contributing to the deficiency.
The facility failed to maintain a clean, safe, and homelike environment, with issues such as a non-functional exit door, foul odors, unsecured windows, and furniture in disrepair. Call lights were often out of reach for residents, compromising their ability to call for assistance. Unsanitary conditions, including urine odors and maintenance issues, were prevalent, and a visitor expressed concerns about a resident's clothing and room conditions.
The facility failed to maintain residents' rights and dignity by not addressing grievances and not responding to call lights in a timely manner. A resident reported issues with a nurse not properly changing his wound dressing and touching his medication with her fingers. Despite voicing these concerns, no grievance form was filled out, and the issues persisted. Additionally, residents experienced long wait times for call light responses, leading to discomfort, pain, and incontinence. The facility's policies on call light accessibility and timely response, as well as the procedure for filing grievances, were not adhered to.
A facility failed to properly assess and monitor a resident after a fall with a head injury and did not complete an incident report for another resident with an injury of unknown origin. The first resident, with severe cognitive impairment, was not given the required neuro checks after returning from the hospital. The second resident, also cognitively impaired, was found with a skin tear and bruise, but the incident was not reported due to a nurse's incorrect assumption about the resident's care plan.
The facility failed to provide adequate respiratory care for three residents, leading to potential health risks. A resident's nebulizer equipment was not properly maintained, with moisture and no replacement date. Another resident's oxygen tank was nearly empty, risking respiratory health. A third resident's nebulizer equipment was improperly stored, with moisture and debris present, and the oxygen concentrator was left on. Facility policies for equipment maintenance were not followed.
The facility failed to properly store medications and needles on the East Wing Unit, with unattended medications and needles found at the nurses' station and on a medication cart. The area was accessible to residents, and the facility's policy requires all drugs and biologicals to be stored in locked compartments.
A resident who required a two-person assist for bed mobility and toileting fell off the bed and sustained a femur fracture when a CNA attempted to change the resident's brief alone. The CNA admitted to knowing the resident's care plan but proceeded alone because other staff were busy.
The facility failed to follow policies for medication labeling and storage, with multiple instances of improperly labeled and unattended medications found in medication carts and the medication room. This included insulin pens, eye drops, nasal sprays, and inhalers without open or expiration dates, indicating systemic issues in medication management.
The facility failed to maintain sanitary conditions in the kitchen, with several expired food items found in storage and improper cleaning of the walk-in cooler fan. This increased the potential for cross-contamination and foodborne illness, potentially affecting 45 residents.
The facility failed to follow standards of practice for administering oral Coumadin and intravenous Vancomycin for two residents, leading to the administration of incorrect dosages despite elevated lab results. This resulted in the likelihood of prolonged illness and/or hospitalization.
The facility failed to ensure timely completion and assessment of diagnostic/laboratory testing and comprehensive monitoring following a change in condition for two residents. One resident experienced a decline in condition and death without proper medical intervention, while another resident's PT/INR levels were not adequately monitored, risking inappropriate Coumadin dosing.
A resident developed an unstageable coccyx pressure ulcer due to the facility's failure to implement timely interventions despite being identified as at risk upon admission. The resident's care plan did not address their pressure ulcer history, and the facility did not follow its clinical protocol for pressure ulcer prevention, leading to the development of the ulcer.
The facility failed to timely assess, investigate, and notify practitioners and the dietitian of a resident's significant weight loss of 32.3 pounds (12.52%) over one month. The reweight was requested but not completed until 11 days later, contrary to the facility's weight monitoring policy.
The facility failed to properly assess and monitor the PICC lines for two residents, resulting in missed dressing changes, flushes, and end cap changes. One resident had a 3.5 cm inward migration of the catheter that was not reported to the physician, while another resident had no documented PICC line care for four days after admission. Both residents had significant medical histories, and the lack of appropriate care posed a risk of complications.
A resident received an unnecessary dose of Coumadin despite elevated PT/INR levels due to the facility's failure to monitor these levels as required. The facility lacked specific policies for Coumadin or PT/INR monitoring, leading to the administration of the medication without appropriate safeguards.
The facility failed to maintain a medication error rate below 5%, resulting in a 30% error rate. Two residents experienced late medication administrations and incorrect dosing, including a stronger dose of Vancomycin given to a resident despite the need for a dose adjustment.
The facility failed to prevent significant medication errors for two residents. One resident received an anticoagulant despite elevated INR levels, and another received the wrong strength of Vancomycin despite elevated trough levels. These errors were due to inadequate documentation, failure to adhere to updated orders, and poor communication among staff.
The facility failed to implement a comprehensive infection control program, leading to inconsistent and incomplete data collection, lack of tracking for potential infections, and inadequate monitoring of antimicrobial stewardship. The IC RN admitted to not having completed training and being unaware of reporting guidelines. Additionally, employee illness tracking and vaccination status monitoring were insufficient, and the laundry and utility rooms were found to be in poor condition.
The facility failed to ensure call lights were within reach and responded to in a timely manner for three residents, and one resident was left exposed. Multiple residents reported long wait times for call light responses, and specific observations confirmed call lights being out of reach and delayed responses, leading to resident frustration and potential mental anguish.
The facility failed to obtain informed consents for non-psychotropic medications used to treat mood and behavior disorders and/or hypnotic medications for seven residents. This resulted in residents receiving medications without the necessary consents, leading to the potential for unnecessary and undesired medication use.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for several residents during meal service and personal care. During a lunch meal service, two residents were left without meals while others at their table were served and finished eating. This delay in meal service was not in accordance with the posted mealtime schedule, and the staff failed to communicate effectively with the kitchen to address the issue. Resident #9, who is legally blind and has severely impaired cognition, and Resident #37, with moderate cognitive impairment, were among those affected by this oversight. In another incident, Resident #27 was exposed without clothing while lying in bed, as the privacy curtain was not closed during care. This resident, who has severe cognitive impairment and requires assistance with bed mobility and dressing, was left in a vulnerable position visible from the hallway. The staff's failure to maintain privacy during care compromised the resident's dignity. Additionally, a group of residents expressed concerns about the responsiveness of staff to call lights, reporting that their needs were often unmet, and call lights were turned off without follow-up. Resident #35's room was noted to have a strong urine odor despite cleaning efforts, indicating a persistent issue with maintaining a dignified living environment. Resident #24 was observed unable to reach their call light, which was on the floor, further highlighting the facility's failure to ensure residents' ability to communicate their needs effectively.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to a deficiency in care. Observations revealed that residents were using silver metal bilateral half siderails without proper documentation or consent. For instance, Resident #8, who has severe cognitive impairment and multiple medical conditions, was observed with siderails in use, but there was no consent or assessment found in their records. Similarly, Resident #14, who is cognitively intact, was using siderails without a physician's order or documented consent, and there was no monitoring for entrapment risks. The facility's care plans for the residents did not address the use, consent, assessment, or monitoring of the siderails. For Resident #19, the 'Informed Consent for Use of Bed Rails' form was incomplete, lacking documented assessments of medical needs, benefits, risks, and alternatives. Resident #43 also had an incomplete consent form, with no identification of the type or location of siderails to be used. These omissions indicate a systemic failure to adhere to the facility's policy on the proper use of bed rails, which requires thorough assessments and informed consent before installation. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, revealed a lack of awareness and compliance with the facility's siderail policy. The staff referred to the siderails as assist bars, and there was confusion about their proper use and documentation. The Director of Maintenance acknowledged that the silver siderails had been in use for a long time without proper evaluation or replacement. This lack of oversight and adherence to policy contributed to the deficiency in ensuring resident safety and compliance with regulatory standards.
Deficiencies in Medication Management and Labeling
Penalty
Summary
The facility failed to ensure proper labeling, storage, and discard of medications across four medication carts, leading to deficiencies in medication management. Observations revealed that multi-dose medications, such as Trelegy Ellipta and insulin pens, were not dated with either an open date or expiration date. Additionally, ampules of Ipratropium Bromide and Albuterol Sulfate were found outside of their foil packets, and a nitroglycerin bottle was missing its red sealed tape and lacked proper dating. Blood glucose strips were also found without an open date, and a loose white tablet was observed in a medication cart drawer. Interviews with staff, including LPNs and RNs, confirmed the lack of adherence to medication labeling and storage policies. The facility's policies on medication storage and labeling were reviewed, revealing that multi-use vials should be labeled with the date they were opened and discarded within 28 days unless otherwise specified. However, the Nursing Home Administrator admitted to the absence of a multi-dose medication policy and an open medication and expiration date policy. The infection control preventionist also confirmed the lack of an ophthalmic medication policy, and no further documentation was provided to address these concerns.
Sanitation and Thawing Procedure Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as to follow correct thawing procedures for hamburger meat. During a kitchen walkthrough, several issues were identified, including a large can opener with dried food on the blade, a small toaster with excessive crumbs, a large mixer with dried batter, and a plate warmer with dried food drippings. Additionally, a black food cart and plastic bowls were found with dried food, and a gray plastic food tray cart had dried food and drippings. A small brush was observed on the handwashing sink, which could transfer bacteria between staff. The facility also failed to maintain proper thawing procedures for hamburger meat. A log of hamburger was observed sitting in a pool of blood in the freezer, which was acknowledged as incorrect by the Infection Control Nurse and the registered dietitian. The facility's Food Preparation and Service policy requires potentially hazardous foods, such as raw meats, to be prepared in specified areas to prevent cross-contamination. However, the facility's Infection Control walk-through checklist previously marked meat thawing as satisfactory, indicating a discrepancy in practice. The dietary staff received education on proper thawing techniques after the observation.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a clean environment for residents, as evidenced by observations of dusty fans and improperly stored oxygen tubing. Resident #41, who has a history of Guillain-Barre Syndrome and other health issues, was observed with a fan blowing directly on him that was covered in dust. Despite multiple observations over consecutive days, the fan remained uncleaned, and the resident confirmed that no one had cleaned it. The Director of Nursing and the Administrator acknowledged the lack of a specific policy for cleaning fans, and the facility's generalized cleaning policy did not specify who was responsible for this task. Resident #42, who is oxygen-dependent, was found with oxygen tubing hanging over a wheelchair without being stored in a bag to prevent cross-contamination. The Director of Nursing admitted there was no policy for storing respiratory equipment properly. Additionally, Resident #54, who requires respiratory treatments, was observed with a dusty fan blowing on him and a urine catheter bag improperly hanging on a trash bin. The Infection Control Nurse indicated that the nurse should have addressed the urinal immediately, but this was not done.
Deficiencies in Care Plan Updates and Safety Measures
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect changing care needs for several residents. Resident #28, who had severe cognitive loss and a history of falls, did not have an updated care plan addressing toileting needs despite multiple falls. Similarly, Resident #47, with severe dementia and a history of falls, had care plans that were not revised after several falls, indicating a lack of proactive measures to prevent future incidents. Resident #60's care plan did not specify the resident's code status preferences, despite the resident choosing to be a Full code. This lack of specificity in the care plan could lead to confusion regarding the resident's advance care planning. Additionally, residents #8, #14, and #19 were observed with bilateral half siderails in use, but their care plans did not address the use, consent, assessment, and monitoring of these siderails, which is a critical oversight in ensuring resident safety. The Director of Nursing was unaware of the siderails' presence, indicating a disconnect between policy and practice. The facility's policy requires comprehensive person-centered care plans, but the observed deficiencies highlight a failure to adhere to this policy, resulting in inadequate care planning and potential safety risks for the residents.
Inaccurate Weight Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate weight measurements for two residents, resulting in incorrect documentation in their medical records. Resident #35 was recorded to have gained 16 pounds in one day, which was later corrected to a 1.7-pound loss after a reweighing prompted by surveyor inquiry. The resident had severe cognitive loss and required assistance with all care. The error was not identified or corrected by the staff until the surveyor's intervention, and the Registered Dietitian (RD) confirmed that weights were not routinely checked for accuracy. Similarly, Resident #47 was documented to have an implausible weight gain of 1,643.5 pounds in one day. This error was also not addressed until the surveyor's involvement. The resident had severe dementia and required assistance with all activities of daily living. The RD stated that she reviewed weights three days a week and would request reweighs if she noticed any abnormal readings. The Director of Nursing acknowledged the issue with weight accuracy in the facility.
Unsanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the clean and dry storage of respiratory equipment for three residents, leading to unsanitary conditions. Resident #25's nebulizer mask was found face down on their nightstand, uncovered and without a barrier. This resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness, confirmed the use of the nebulizer. Infection Control (IC) Nurse A stated that nebulizer masks should be cleaned, dried, and stored in a bag, which was not followed in this case. Resident #44's CPAP face mask was stored uncovered inside a metal basket, and their coughing machine mouthpiece was in direct contact with the back of the oxygen concentrator. This resident, with diagnoses including Amyotrophic Lateral Sclerosis (ALS), COPD, and Obstructive Sleep Apnea, required assistance with their respiratory equipment. IC Nurse A acknowledged that the storage of Resident #44's equipment was unacceptable. Resident #54's respiratory treatment mask was observed sitting on a window sill on top of a clear plastic bag, contrary to the IC Nurse's statement that it should be placed on a paper towel to dry before being stored in a plastic bag. The Director of Nursing confirmed the absence of a specific policy for storing respiratory equipment in plastic bags, although it was expected practice.
Failure to Monitor Antibiotic Use and Update Line Listings
Penalty
Summary
The facility failed to adequately monitor the antibiotic use for a resident who was receiving Gentamycin sulfate through a suprapubic catheter. The medication was prescribed to be administered three times a week, but the resident only allowed it to be administered twice a week during showers. This discrepancy was known to the resident's mother and physician. However, the facility did not update the antibiotic line listing to reflect this resident's use, and the resident was not included in the infection control line listings for several months. The RN Infection Control nurse was unaware of the omission of the resident from the line listings and acknowledged that the resident's Gentamycin use had not been monitored or tracked since 2023. Despite the urologist's indefinite order for the medication, the RN noted that the treatment appeared ineffective based on the resident's lab results. The lack of monitoring was recognized as a potential issue for the growth of MDROs, and the RN confirmed that the resident's antibiotic use should have been included in the monthly line listings.
Inadequate Evening Snack Provision
Penalty
Summary
The facility failed to provide an adequate amount and variety of evening snacks for a group of residents, leading to dissatisfaction and frustration among them. Residents reported that the snack carts were not restocked regularly, and the available snack items were limited and repetitive. Complaints included the absence of snack distribution at night, the removal of the snack cart, and a lack of variety in the snacks provided, such as limited fruit choices and insufficient protein options. Residents expressed a desire for more diverse snacks, including different types of sandwiches, chips, and cookies. Observations and interviews with dietary staff revealed that the snack carts were stocked with a limited number of items, such as peanut butter and jelly sandwiches, chips, cookies, and a few fruit options. The nourishment refrigerator contained minimal protein snacks, primarily cottage cheese, and a small number of other items like puddings and meat sandwiches. The dietary staff indicated that the snack carts were stocked with about 4 or 5 of each item, and there was no access to the kitchen after staff left for the night. The Resident Council Minutes also highlighted ongoing concerns about the lack of snack distribution, indicating that the issue had been persistent over time.
Failure to Provide Adequate ADL Care Leads to Skin Issues
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident who was dependent on staff assistance, resulting in poor skin conditions and insufficient help with bed mobility and peri-care. The resident, who is cognitively intact with a BIMS score of 15, reported issues with staff response times when needing assistance after episodes of fecal incontinence. The resident experienced delays in being cleaned up and repositioned, leading to being left in urine or feces for extended periods. This neglect contributed to the development of sores on the resident's buttocks, which were noted to be improving. Upon admission, the resident did not have any skin conditions, but later developed moisture-associated skin damage (MASD) on the coccyx, as documented in a wound evaluation form. Interviews with the Wound Nurse and the Director of Nursing revealed that the resident's skin issues were attributed to frequent urinal spills and loose stools, which kept the skin wet, as well as potential shearing from a Hoyer sling. The facility's policy on ADLs emphasizes the importance of maintaining residents' functional abilities, including personal hygiene, which was not adequately upheld in this case.
Medication Availability and Timeliness Deficiency
Penalty
Summary
The facility failed to ensure the availability and timely administration of physician-ordered medications for two residents. Resident #1, who was admitted with a pathological fracture, rib fracture, and cancer, did not receive prescribed pain medications, Hydromorphone and Morphine, upon admission. The complainant reported that the pain medications were unavailable for approximately 24 hours, leading the resident to call 911 and leave the facility to obtain pain relief. The Director of Nursing (DON) confirmed that the medications were not available onsite and explained that the process for obtaining pain medication was delayed due to the need for physician orders to be entered into the electronic medical record (EMR) before medications could be accessed. Resident #2, admitted with spinal stenosis, a history of falling, atrial fibrillation, and chronic obstructive pulmonary disease, also experienced a delay in receiving medications. The resident reported a delay of over 24 hours in receiving both pain medications and general medications, including Eliquis. The electronic medical record revealed that doses of Eliquis were missed on two consecutive days. The facility's medication administration policy, which requires medications to be administered within 60 minutes of the scheduled time, did not address the availability of medications in backup, contributing to the deficiency.
Environmental and Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by multiple observations of environmental deficiencies across two units. On the Central Unit, an exit door was improperly latched shut, rendering it non-functional in case of an emergency. Additionally, there were foul odors, unsecured windows, and furniture in disrepair. On the East Wing Unit, call lights were consistently found out of reach for residents, compromising their ability to call for assistance when needed. Several specific instances highlighted these deficiencies. In one room, a resident was unable to reach their call light, which was positioned almost on the floor. Another resident's call light was clipped to the wall, out of reach, and a nurse had to reposition it. Observations also noted call lights on the floor in multiple rooms, indicating a systemic issue with ensuring residents' access to call lights. Furthermore, a resident reported that call light response times could exceed half an hour, suggesting inadequate staffing or response protocols. The facility's environment was further compromised by unsanitary conditions, including urine odors in rooms and bathrooms, dried substances on walls, and broken furniture. Maintenance issues were prevalent, such as missing outlet covers, non-functional cold water taps, and holes in bathroom walls. The Maintenance Director acknowledged these issues but indicated a lack of communication from staff regarding environmental concerns. A confidential visitor also expressed concerns about a resident's clothing and room conditions, further underscoring the facility's failure to provide a safe and homelike environment.
Failure to Address Grievances and Timely Call Light Response
Penalty
Summary
The facility failed to maintain residents' rights and dignity by not addressing grievances and not responding to call lights in a timely manner for four residents. Resident #2, who had intact cognition, reported issues with a nurse not properly changing his wound dressing and touching his medication with her fingers. Despite voicing these concerns to Nurse B, no grievance form was filled out, and the issues persisted. Additionally, Resident #2 experienced long wait times for call light responses, leading to discomfort and pain when left on a bedpan for an extended period. Resident #3, with moderately impaired cognition, was observed in a wheelchair without foot pedals and with a stained gown, indicating possible neglect. The resident's call light was not within reach, and she reported long wait times for staff response. Resident #6, who had intact cognition, also reported long wait times for call light responses, resulting in incontinence. Resident #9, who was independent in cognitive skills, confirmed similar issues with call light response times, particularly during the night shift. The facility's policies on call light accessibility and timely response, as well as the procedure for filing grievances, were not adhered to. Staff interviews revealed a lack of consistent documentation and follow-up on resident complaints. The facility's failure to address these issues resulted in unmet needs and compromised resident dignity.
Deficiencies in Fall and Injury Management
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident, identified as Resident #11, after a fall that resulted in a head injury. The resident, who had severe cognitive impairment due to dementia and seizures, was involved in an incident where another resident pushed her, causing her to fall and hit her head. Although she was sent to the hospital for evaluation, upon her return, the facility did not conduct the necessary neuro checks as per their policy, which should have been done every 12 hours. This oversight was acknowledged by the Director of Nursing (DON), who admitted that the follow-up assessment for the fall was missed. Another deficiency involved Resident #12, who also had severe cognitive impairment and was found with a skin tear and a bruise, suggesting a possible fall. The incident was not reported immediately because a nurse mistakenly believed the resident was care planned to sit on the floor. This assumption led to a delay in completing an incident report and conducting a thorough investigation. The DON confirmed that the resident was not care planned to be on the floor, and the failure to report the skin tear as an injury of unknown origin delayed the necessary investigation and assessment. The facility's deficiencies in handling these incidents resulted in potential risks for the residents involved. The lack of timely reporting and assessment could have led to undetected injuries or abuse, particularly for Resident #12, whose injuries were not immediately investigated. These failures highlight significant lapses in the facility's procedures for managing falls and injuries of unknown origin, as well as in their communication and documentation practices.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to potential health risks. Resident #2's nebulizer equipment was not properly maintained, as it was observed with moisture in the medication chamber and lacked a replacement date. Despite being informed, the nurse did not replace the equipment, and the resident reported not receiving new equipment over the weekend. This negligence in maintaining the nebulizer equipment could lead to respiratory infections. Resident #5 was observed with an oxygen tank that was nearly empty while sitting in a common area. The resident's oxygen order required continuous oxygen at 2 L/min, but the tank's dial was in the red zone, indicating a lack of oxygen. The CNA responsible for the resident's care reported checking the tank earlier, but it was not adequately monitored, risking the resident's respiratory health. Resident #8's nebulizer equipment was improperly stored, with moisture and debris present in the mask and medication chamber. The oxygen concentrator was left on, and the nasal cannula was visibly soiled without a replacement date. The facility's policy required weekly changes and proper drying of equipment, which was not followed, increasing the risk of mold or mildew formation and potential respiratory issues for the resident.
Improper Storage of Medications and Needles
Penalty
Summary
The facility failed to properly store medications and needles on the East Wing Unit, which was observed during a survey. At the nurses' station, a bag of multiple antibiotic IV medications, a tube of Derma fungal cream, Assure glucometer control solution, a vial of Ertapenem, and Assure ID Pen needles were found unattended on the counter. The area was accessible to residents, and there were no staff present at the time of observation. The Nursing Home Administrator was informed of the unattended medications and needles and subsequently retrieved the nurse responsible for the area, who acknowledged that the medications should not have been left unattended. Additionally, an observation of a nurse's medication cart in the East Wing hallway revealed an open box of needles on top of the cart while the nurse was administering medications to residents. The nurse confirmed that the needles should not have been left on top of the cart and removed them. The facility's policy on medication storage, which was reviewed and revised earlier in the year, mandates that all drugs and biologicals be stored in locked compartments to ensure security and proper conditions. The failure to adhere to this policy resulted in the potential for medication ingestion, diversion, and injury.
Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to abide by a resident's assessed level of assistance during incontinence care, resulting in the resident rolling off her bed and sustaining a preventable femur fracture. The resident, who is cognitively intact and able to make her needs known, required a two-person assist for bed mobility and toileting. However, a CNA attempted to change the resident's brief alone, leading to the resident falling off the bed and requiring surgical intervention for a femur fracture. The incident occurred when the CNA placed the resident on a bedpan and then attempted to change the brief alone. The resident was already close to the edge of the bed, and the CNA was not paying sufficient attention to her positioning. As the CNA was changing the brief, the resident rolled toward the right side and fell off the bed. The CNA admitted to knowing that the resident required a two-person assist but proceeded alone because other staff were busy. Interviews with the CNA and nursing staff confirmed that the resident's care plan and Kardex indicated a two-person assist for bed mobility and toileting. The CNA acknowledged that she did not follow the proper procedure and that she had been trained on turning and repositioning just days before the incident. The facility conducted a sweep of like residents and provided additional training and competency checks for CNAs to ensure compliance with care plans.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to follow policies and procedures for medication labeling and storage, as observed in two medication carts and one medication room. Specifically, the East Unit Medication cart was found unlocked and unattended, allowing the state surveyor to access medication drawers. The responsible RN admitted to leaving the cart unattended while attending to other tasks. Additionally, multiple instances of improperly labeled medications were found, including insulin pens, eye drops, nasal sprays, and inhalers without open or expiration dates. These deficiencies were observed across multiple residents' medications, indicating a systemic issue in medication management and storage practices. Further observations in the medication room revealed additional labeling and storage issues. For example, a multi-dose Novolog insulin bottle and a tuberculin multi-dose bottle were found without open dates. The medication refrigerator also contained improperly labeled medications, including a COVID-19 injection and a multi-dose Novolog insulin bottle. These findings suggest a failure to adhere to the facility's policies on medication storage and labeling, potentially compromising medication efficacy and resident safety.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During a tour of the kitchen, several expired food items were found in the dry storage room, cook refrigerator, and walk-in cooler. These items included expired packets of sugar-free raspberry gelatin, hard shell tacos, a 5-pound bag of corn muffin mix, a 50-pound container of rice, and 3-gallon containers of various cereals. Additionally, a 5-quart container of salad mix in the cook refrigerator and several gallon-sized bags of frozen meats in the walk-in cooler were either expired or lacked proper date marking. The facility's staff, including the Dietary Cook and Certified Dietary Manager, acknowledged that it was the responsibility of all kitchen staff to discard expired food items, but this was not being adequately performed. Furthermore, the walk-in cooler fan was observed to be soiled, indicating a lack of proper cleaning and maintenance. The Certified Dietary Manager confirmed that kitchen staff are responsible for discarding expired food as they access these areas daily for meal preparation. The facility's failure to adhere to the 2013 FDA Food Code section on date marking and proper food storage practices was evident, as expired and improperly dated food items were found throughout the kitchen. This deficiency potentially affected 45 residents who consume meals prepared in the kitchen.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to follow the standards of practice for the administration of oral Coumadin and intravenous Vancomycin medications for two residents. For Resident #100, the facility did not consistently document PT/INR levels on the Medication Administration Record (MAR) and administered Coumadin despite elevated INR levels. Specifically, the MAR showed blank entries for PT/INR on several dates, and Coumadin was given on a date when the INR was significantly elevated, contrary to the standard practice of holding the medication in such cases. Interviews with the Nurse Practitioner and Licensed Practical Nurse confirmed that the medication should not have been administered without knowing the PT/INR levels, highlighting a lapse in following the nursing standard of practice for high-risk medications like Coumadin. For Resident #200, the facility failed to properly adjust the dosage of Vancomycin based on elevated trough levels. The MAR indicated that the Vancomycin dosage was changed from 750 mg/250 ml to 500 mg/100 ml due to elevated trough levels. However, the night shift nurse administered the higher dose despite the change in orders. Interviews with the LPN and Unit Manager revealed that the elevated trough levels were known, and the incorrect dosage was still administered, indicating a failure to adhere to the updated medication orders and proper monitoring protocols. These deficiencies in medication administration practices for both residents resulted in the likelihood of prolonged illness and/or hospitalization. The facility's failure to document and act on critical lab results and medication orders demonstrates a significant lapse in adhering to professional standards of quality care, as outlined in the facility's policies and nursing standards of practice.
Failure to Monitor and Assess Residents' Conditions
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure timely completion and assessment of diagnostic/laboratory testing as well as comprehensive assessment, monitoring, and treatment following a change in condition for two residents. For Resident #49, the facility did not conduct necessary laboratory tests, failed to reassess abnormal vital signs, and did not involve the resident in care decisions despite the resident being cognitively intact and capable of making their own medical decisions. The resident experienced a decline in condition, including symptoms of pneumonia and hypoxia, but the facility did not adequately monitor or respond to these changes, leading to the resident's death without proper medical intervention or transfer to a hospital as needed. Resident #49 was admitted with diagnoses including Covid-19, pneumonia, congestive heart failure, and diabetes mellitus. Despite being on a course of oral steroid therapy and antibiotics, the resident's condition worsened, showing signs of pneumonia and hypoxia. The facility's documentation revealed inconsistencies in oxygen administration and a lack of follow-up on abnormal vital signs, such as hypotensive blood pressure readings. Additionally, there was no documentation of a urinalysis that was indicated in the nursing notes, and the resident's decreased intake and output were not adequately monitored. For Resident #100, the facility failed to monitor PT/INR levels as required for a resident on Coumadin therapy for atrial fibrillation. The Medication Administration Record (MAR) showed blank entries for scheduled PT/INR tests, and there was no documentation of the nurses monitoring these critical lab results. This lack of monitoring could have led to inappropriate dosing of Coumadin, as evidenced by an elevated INR level that was not addressed in a timely manner. The facility's failure to adhere to its own policies for monitoring high-risk medications resulted in a significant deficiency in the care provided to Resident #100.
Failure to Implement Timely Interventions for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement timely interventions to prevent an unstageable coccyx pressure ulcer for a resident, resulting in the development of a new unstageable pressure ulcer. The resident, admitted with diagnoses including diabetes, anemia, and heart failure, required extensive assistance with activities of daily living and had intact cognition. Despite being identified as at risk for impaired skin integrity upon admission, there was no care plan implemented for the resident's pressure ulcer history and Braden scale score. The resident's electronic medical record indicated no skin issues upon admission, but a new skin problem was observed ten days later, leading to the development of an unstageable pressure ulcer on the coccyx, which was in-house acquired and measured 5.42 cm by 3.02 cm initially and later 5.68 cm by 1.88 cm, showing some improvement by May 1st. The facility's clinical protocol for pressure ulcer prevention, revised in January 2022, emphasizes the importance of an admission evaluation to identify residents at risk and implement prompt interventions. However, the facility did not adhere to this protocol, as evidenced by the lack of a care plan for the resident's pressure ulcer history and the delayed response to the resident's skin issues. The Director of Nursing and Unit Manager acknowledged the deficiency but suggested the ulcer was unavoidable, without providing additional documentation to support their claim. This failure to follow established protocols and timely implement preventive measures led to the resident developing a new unstageable pressure ulcer, highlighting a significant lapse in care and oversight.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to timely assess, investigate, implement appropriate interventions, and notify practitioners and the dietitian of significant weight loss for one resident. Resident #13 experienced a significant weight loss of 32.3 pounds (12.52%) over one month, which was not promptly addressed by the facility. The resident's care plan included notifying the dietitian and physician of significant weight changes, but this was not done in a timely manner. The resident's weight dropped from 257.9 lbs on 12/05/2023 to 225.6 lbs on 01/09/2024, yet there were no nursing progress notes regarding the weight loss or notifications to the dietitian or practitioners during this period. The Registered Dietitian requested a reweight on 1/11/2024, but it was not completed until 1/22/2024, 11 days after the request and 13 days after the initial weight was recorded. The facility's policy on weight monitoring, revised on 10/26/2023, states that significant changes in weight should be promptly addressed and the physician and dietitian should be informed. However, this policy was not followed, resulting in delayed assessment and intervention for Resident #13's significant weight loss.
Failure to Properly Monitor and Document PICC Line Care
Penalty
Summary
The facility failed to properly assess and monitor the PICC lines for two residents, resulting in significant deficiencies in care. Resident #39 had a PICC line inserted for IV antibiotics but did not have any documented PICC line assessments or care orders until 13 days after admission. This lack of documentation included missed dressing changes, flushes, and end cap changes. Additionally, a 3.5 cm inward migration of the catheter was noted but not reported to the physician, which could lead to further complications. The Director of Nursing and Unit Manager confirmed the absence of PICC assessments prior to the 13th day of admission. Resident #200 also experienced deficiencies in PICC line care. Upon admission, the resident's PICC line dressing was not occlusive, dated, or initialed, and there were no orders for PICC line care until four days after admission. The resident's MAR/TAR did not include any documented measurements for arm circumference or catheter length, and the first documented PICC line treatment was recorded 11 days after admission. Nurse D confirmed that the admission assessment should have prompted the input of PICC line orders, but this did not occur. Both residents had significant medical histories, including osteomyelitis, diabetes, mood disorder, atrial fibrillation, dementia, and sepsis. The lack of timely and appropriate PICC line care and documentation posed a risk of complications such as infection, thrombosis, and further catheter migration. The facility's failure to adhere to standards of practice for PICC line care was evident in the observations, interviews, and record reviews conducted by the surveyors.
Failure to Monitor PT/INR Levels Before Administering Coumadin
Penalty
Summary
The facility failed to ensure that a resident was free from an unnecessary dose of Coumadin, an anticoagulant, despite elevated laboratory Protime (PT) and International Normalized Ratio (INR) levels. The resident, who had multiple medical diagnoses including atrial fibrillation and heart failure, was supposed to have PT/INR levels monitored three times a week. However, the Medication Administration Record (MAR) showed blank entries for several scheduled PT/INR checks, and the medication was administered without proper monitoring of these levels. Specifically, the resident received Coumadin on a day when their PT/INR levels were significantly elevated, which was against the standard practice of holding the medication in such cases. This oversight was confirmed through interviews with the Nurse Practitioner and Licensed Practical Nurse, who both acknowledged that the medication should not have been given under these circumstances. Further review revealed that the facility's medication administration policy did not include instructions for nurses to monitor therapeutic laboratory levels prior to administering high-risk medications like Coumadin. The Director of Nursing confirmed that the facility lacked specific policies for Coumadin or PT/INR monitoring. This deficiency in policy and practice led to the administration of a high-risk medication without appropriate safeguards, increasing the likelihood of excessive bleeding and potential hospitalization for the resident.
High Medication Error Rate Due to Late Administration and Incorrect Dosing
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5%, resulting in a medication error rate of 30%. This was observed through 7 late administrations of medications and 2 medication errors out of 30 opportunities for two residents. Specifically, Resident #200 experienced a medication error when a stronger dose of Vancomycin was administered by the night shift, despite the need for a dose adjustment due to elevated lab values. Additionally, the resident's morning medications were administered significantly later than the policy's 60-minute requirement. Resident #100 also received their 8:00 AM medications at 9:26 AM, which is beyond the allowed time frame. During the survey, it was observed that the call light for Resident #200 was left out of reach, and the resident's PICC line dressing was dated incorrectly. The pharmacy had sent four doses of Vancomycin 500 mg/100 ml, but none were administered as ordered. Both LPNs D and E were still passing morning medications well past the scheduled time. These observations and record reviews highlight the facility's failure to adhere to its medication administration policy, leading to a high medication error rate and potential risks for the residents involved.
Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. For Resident #100, a nurse administered Coumadin, an anticoagulant, despite an elevated INR level of 3.58, which increased the likelihood of bleeding or hospitalization. The facility's policy required PT/INR levels to be checked three times a week, but the results were not consistently documented in the Medication Administration Record (MAR). The nurse administered the medication without verifying the elevated INR level, contrary to the facility's guidelines and professional standards of practice. For Resident #200, a nurse administered the wrong strength of Vancomycin, an antibiotic, despite elevated Vancomycin trough levels. The resident was initially prescribed 750 mg of Vancomycin twice daily, but due to elevated trough levels, the dose was adjusted to 500 mg. However, the night nurse administered the previous higher dose of 750 mg, ignoring the updated order. This error was identified when the new dose was found in the medication storage room, indicating that none of the new doses had been administered as ordered. Both incidents highlight a failure in the facility's medication administration process, including inadequate documentation, lack of adherence to updated medication orders, and insufficient communication among staff. These deficiencies resulted in significant medication errors that could have led to prolonged illness and hospitalization for the affected residents.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, which included outcome and process surveillance, accurate data collection, documentation, and analysis. The infection control data for March 2024 was inconsistent and incomplete, with discrepancies in the number of infections reported on different documents. The Infection Control (IC) Registered Nurse (RN) V, who started in February 2024, admitted to not having completed their organizational training and being unaware of reporting guidelines related to communicable diseases. The line listing did not include essential details such as carry-over infections, room numbers, isolation precautions, diagnostic testing results, and antimicrobial treatment duration. Additionally, the facility was not reporting Covid-19 or other communicable diseases to the Health Department, and there was a lack of tracking for potential infections and symptoms among residents not receiving antimicrobial treatment. The facility's infection control program also failed to track and monitor antimicrobial stewardship effectively. RN V was unable to quickly access and verify if infections met the criteria for treatment, and the monthly summary for March 2024 did not address residents who received treatment without meeting the criteria. Specific cases, such as Resident #26 and Unsampled Residents A and B, highlighted issues with documentation and tracking of infection onset dates, diagnostic testing, and antibiotic administration. RN V admitted to not tracking potential infections and contagious microorganisms, which is crucial for mitigating the spread of illness. Employee call-in and illness tracking were also inadequate, with the list for March 2024 lacking details related to infection tracking. RN V was unaware of how contracted staff call-ins and illnesses were reported and tracked. The facility did not have a comprehensive system for tracking resident vaccination status for influenza and pneumococcal vaccines. Additionally, process surveillance and rounding were minimal, and the laundry and utility rooms were found to be in poor condition, with issues such as dirty and cluttered environments, improper storage of PPE, and uncovered oxygen concentrators. The Director of Nursing (DON) acknowledged the concerns but did not provide a clear plan for addressing the deficiencies.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure call lights were within reach and responded to in a timely manner for three residents, and one resident was left exposed. During a Resident Council meeting, multiple residents reported waiting over 30 minutes for call light responses, with some waiting over an hour. Specific observations included Resident #15's call light being out of reach on multiple occasions, Resident #100 being left exposed in a wet brief with the door open, and Resident #200's call light being placed out of reach. Additionally, Resident #6's call light was activated for nine minutes without staff response, and further delays were noted in assisting the resident out of bed. The facility's policies on promoting resident dignity, resident rights, and call light accessibility were not adhered to, as evidenced by the observations and resident reports. Staff members were observed not placing call lights within reach and not responding promptly, leading to residents experiencing frustration and potential mental anguish. The deficiencies were noted across different shifts and involved multiple staff members, indicating a systemic issue in the facility's adherence to its policies and procedures.
Failure to Obtain Informed Consents for Mood Stabilizers and Hypnotics
Penalty
Summary
The facility failed to ensure that informed consents were obtained for non-psychotropic medications used to treat mood and behavior disorders and/or hypnotic medications for seven residents. This resulted in residents receiving medications without the necessary consents, leading to the potential for unnecessary and undesired medication use. The facility's policy stated that psychotropic drugs should only be given when necessary to treat a specific condition and must be documented in the clinical record. However, the facility did not obtain consents for medications such as Lamictal, Depakote, Topamax, and Ramelteon, which were used as mood stabilizers or hypnotics for various residents with mood disorders, bipolar disorder, and dementia with behavioral features. During the survey, it was found that the social services designee was unaware that consents were needed for mood stabilizers. Upon realizing the oversight, the designee conducted an audit and identified seven residents who required consents for their medications. The residents involved had conditions such as bipolar disorder, mood disorders with psychotic features, and dementia with behavioral disturbances, and were prescribed medications like Depakote, Lamictal, and Topamax without the proper consents. This lack of informed consent was a significant deficiency in the facility's medication administration process.
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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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