Medilodge Of Grand Blanc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Blanc, Michigan.
- Location
- 11941 Belsay Road, Grand Blanc, Michigan 48439
- CMS Provider Number
- 235226
- Inspections on file
- 30
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Medilodge Of Grand Blanc during CMS and state inspections, most recent first.
Multiple residents reported and were observed experiencing delayed responses to call lights, inaccessible call light devices, and undignified staff interactions. Several residents with intact cognition described waiting 30 minutes or longer for assistance, including while on the toilet and when requesting pain medication, with staff sometimes turning off call lights and not returning. Other residents with impaired cognition, hemiplegia, ventilator dependence, and limited hand use were observed with call lights on the floor, covered by items, or otherwise out of reach, requiring them to yell or throw objects to get help. A confidential group of residents and a family member agreed that call lights are often out of reach, response times are long, staff may become upset when call lights are reactivated, and staff engage in personal conversations and talk about other residents within earshot instead of addressing the resident directly.
Surveyors identified that multiple dependent residents did not receive consistent ADL and hygiene care, including bathing, nail trimming, shaving, and routine personal hygiene. Several residents with cognitive impairment, ventilator dependence, stroke‑related deficits, and other serious conditions were observed with long, jagged or unkempt fingernails (sometimes digging into the skin), greasy or debris‑filled hair, unkempt beards despite stated preference for shaving, dried secretions on the face, mucous in the eyes, and pervasive offensive odors in a room. EMR review showed missed or undocumented scheduled baths, lack of documentation of nail care, and no progress notes describing reapproach attempts after refusals or reasons for incomplete bathing. Care plans often lacked specific interventions for refusals of care or grooming needs such as facial hair, demonstrating that ADL care and related documentation were not consistently implemented for these residents.
A resident with severe cognitive impairment and multiple medical conditions was found with a padded full side rail in use without a care plan, physician order, informed consent, or required assessments. Facility staff confirmed that no assessment, consent, or entrapment measurements were completed, and the use of side rails was not documented in the care plan, contrary to facility policy.
Two residents requiring Enhanced Barrier Precautions due to complex medical conditions and infection risks did not have proper signage posted or adequate PPE available as required by their care plans and facility policy. Staff were unable to locate necessary PPE or signage, and care activities were not conducted in accordance with established infection control protocols.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
Two residents with complex medical conditions experienced repeated episodes of constipation, with extended periods without bowel movements, despite care plans and a facility bowel protocol intended to address such issues. Documentation showed that interventions were not consistently implemented in a timely manner, and both residents exhibited symptoms such as emesis, restlessness, and resistance to care during these episodes. Both also experienced falls during periods of constipation, and staff interviews confirmed that the bowel protocol was not always followed as required.
A resident with multiple medical conditions experienced a significant change in condition, including increased fatigue, refusal to eat, and decreased responsiveness, leading to interventions such as oxygen therapy, CPAP, IV fluids, and Narcan administration. Despite facility policy requiring prompt notification, the resident's representative was not informed of these changes until the following day, and documentation of notification was missing. Staff interviews confirmed that the required notification did not occur in a timely manner, resulting in the family being unaware of the resident's status and interventions.
Two residents experienced neglect and abuse by a nurse aide who failed to respond to call lights and provide necessary care. One resident, dependent on a ventilator, was left soiled for hours, leading to distress and suicidal thoughts. Another resident was denied assistance with oral secretions and subjected to inappropriate language, causing discomfort and stress. The facility's policies on abuse and dignity were not followed, and care plans were not adhered to.
The facility's kitchen was found to have unsanitary conditions, including debris in refrigerator handles, soiled floors, and improper dish sanitization due to a malfunctioning dishwasher. Cleaning logs showed incomplete tasks, and expired food items were found in storage. The facility's cleaning schedule was not adhered to, and a boiler issue was identified as affecting water temperature.
The facility failed to promptly act on positive influenza results for two residents, who attended a Resident Council meeting without masks, exposing others. The DON and Infection Preventionist acknowledged the residents should not have been invited. Delays in receiving test results prevented timely precautions and interventions, and the facility did not offer alternative activities for the residents in isolation.
The facility's activities program was found to be monotonous and unoriginal, failing to meet the interests and needs of residents. Nine residents expressed dissatisfaction with the repetitive and poorly organized activities, which were often gender-biased and did not cater to cognitively intact individuals. The Activities Director admitted to copying and pasting activities from month to month and did not address the lack of resident-specific programming. Additionally, the facility's bus could not accommodate more than one resident with a specialty wheelchair, limiting participation in outings.
The facility failed to maintain a clean and safe environment, with soiled privacy curtains, improperly stored respiratory equipment, and unclean common areas. Residents' call lights were not within reach, posing safety risks. Respiratory equipment was found next to unsanitary items, lacking proper labeling and dating. The Infection Control Preventionist acknowledged improper storage of personal items, and the Maintenance Director was unaware of a ceiling tile issue causing a draft in a shared bathroom.
A facility failed to develop and implement a comprehensive activity care plan for a resident on mechanical ventilation, who expressed a desire to participate in activities outside their room. The resident reported staff unresponsiveness to requests for assistance and insufficient staffing to facilitate their participation in desired activities. The resident's electronic medical record lacked an activity care plan, contrary to facility policy, and the DON confirmed this oversight without explanation.
A resident with a history of COPD, influenza, and sepsis experienced a delay in treatment for pneumonia due to lapses in the facility's processes. Despite showing symptoms such as a cough and high temperatures, there was a delay in reviewing lab results and administering appropriate antibiotics. The resident's condition was not promptly addressed, leading to a potential exacerbation of their illness.
A resident returned from the ER with a urinary catheter, but the LTC facility failed to document its presence or provide necessary care. The resident's medical record lacked any mention of the catheter, and staff were unaware of its existence, leading to inadequate assessment and monitoring. The facility's policy on catheter care was not followed, resulting in a deficiency.
A facility failed to ensure proper head of bed elevation during tube feeding for a resident, resulting in a deficiency. The resident, with a complex medical history and requiring mechanical ventilation and tube feeding, was observed with the bed elevated at 24 degrees, below the recommended 30-degree minimum. The facility's policy lacked specific guidance on head elevation during feeding.
A facility failed to flush a PICC line after administering IV Cefepime to a resident with ALS and other complex medical conditions. The RN acknowledged the oversight, and the DON confirmed the requirement to flush PICC lines post-medication. The resident's care plan lacked PICC line monitoring, and the facility's policy required flushing before and after infusions.
A resident with serious health conditions did not receive prescribed medications Bumetanide and Spironolactone on multiple occasions due to delays in obtaining them from the pharmacy. The DON and ADON were unaware of the issue, and the facility failed to utilize available back-up medication. No documentation of communication with the pharmacy or practitioner was found.
A resident with multiple health conditions did not receive prescribed doses of Bumetanide and Spironolactone on several occasions due to delays in pharmacy delivery. The DON and ADON were unaware of the issue, and there was no documentation of communication with the practitioner about the missed doses, leading to significant medication errors.
A resident with multiple health issues, including influenza, was not documented as having been offered or received the influenza vaccine, nor was there a record of refusal. The ICP could not find the resident's immunization information, and the resident's name was missing from the audit report. Facility policies require annual offering and documentation of influenza vaccinations, which was not adhered to in this case.
The facility failed to provide dignified and respectful care, resulting in deficiencies for several residents. A resident dependent on a ventilator experienced delayed staff response, leading to incontinence and feelings of embarrassment. Another resident with dysphagia was left unsupervised during meals, contrary to their care plan. In the dining area, residents used towels instead of proper shirt protectors due to a shortage, and a resident was exposed during a transfer due to inadequate privacy measures.
The facility failed to provide timely ADL care and supervision for three residents, leading to discomfort and frustration. A resident was left in a broken bed without incontinence care, another experienced long call light wait times resulting in incontinence, and a third resident with swallowing precautions ate unsupervised, risking aspiration.
A facility failed to implement care-planned safety and supervision interventions for three residents, leading to potential and actual harm. A resident with multiple sclerosis was transferred by a single CNA instead of two, another resident with severe cognitive impairment lacked accessible call light and fall mats, and a resident with dysphagia ate unsupervised despite needing meal supervision.
A facility failed to dispose of oxycodone and maintain accurate medication records for a resident. The Controlled Substance Log was disorganized, with missing nurse initials and a missing pill from the blister pack. The resident's oxycodone order had been discontinued months prior, and there was no documentation of administration. The DON and Unit Manager revealed the pill was meant to be wasted due to blister pack damage, but this was not documented. The facility's policy on controlled substances was not followed.
A resident with cognitive decline and multiple health issues was verbally abused by a staff member in the dining room. The staff member, who had a history of inappropriate behavior, told the resident to "shut your mouth," which was overheard by other staff. The facility's policy on preventing abuse was not effectively implemented.
The facility failed to prevent an overdose for a resident with a history of substance abuse by not informing practitioners of the history and applying a fentanyl patch in an accessible area. Additionally, the facility did not ensure a safe environment or conduct thorough investigations for falls involving two residents, leading to potential harm and a decline in their conditions.
A nurse failed to properly secure her PPE gown during PEG tube care for a resident with complex medical needs, leading to potential contamination. The gown was not tied at the neck and waist, resulting in it tearing and falling off during the procedure, contrary to the facility's PPE policy.
A resident with an acute displaced fracture of the right ankle did not consistently receive pain assessments or medication as ordered, leading to prolonged periods of unmanaged pain. Despite reporting high pain levels, there were significant delays in administering prescribed pain medication. Interviews with the DON acknowledged the concerns, but no satisfactory explanation was provided for the inconsistencies, which were contrary to the facility's pain management policy.
Failure to Ensure Accessible Call Lights, Timely Responses, and Dignified Interactions
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, communication, and timely assistance by not ensuring call lights were accessible and responded to promptly. One resident with chronic obstructive pulmonary disease, chronic pain, respiratory failure, a history of falls, and intact cognition reported that when she activated her call light, it sometimes took 30 minutes to an hour for staff to respond, especially at night. She stated that this delay also affected her ability to receive pain medication, as she first had to wait for staff to answer the call light and then wait longer to actually receive the medication. Another resident with intact cognition who required substantial/maximal assistance with toilet transfers and toileting hygiene reported being left on the toilet for about 30 minutes and stated that he sometimes had to wait more than 30 minutes for assistance, mostly on night shift. He described that nurses would answer the call light, turn it off, say they would notify someone, and then not return, requiring him to turn the call light back on after about 10 minutes when no one came. The facility also failed to ensure that call lights were consistently within reach for several residents with significant functional and cognitive impairments. One resident with moderately impaired cognition who required substantial/maximal assistance with personal hygiene, rolling, and was dependent for transfers, dressing, and toileting was observed lying in bed with the bed in a high position and the call light placed on a Geri chair, covered by items, and out of his sight and reach. He reported that the call light often fell on the floor and that he resorted to throwing objects at the door to get staff attention. A nurse, when alerted, acknowledged that the resident should have had the call light in reach and then repositioned it and lowered the bed. Another resident with severe cognitive impairment, hemiplegia and hemiparesis, muscle wasting, atrophy, and attention and concentration deficits was observed with the call light lying on the floor at the head of the bed and not within reach; a CNA confirmed it should not have been on the floor and then clipped it to the resident’s blanket. The resident’s care plan specifically included an intervention to place the call light within reach. Additional concerns were identified through a confidential group meeting with residents and a family member, as well as with a resident dependent on a ventilator. The group reported that they all wait a long time for call lights to be answered and that staff often enter the room, turn off the call light without completing the requested task, or say they will return and do not, then become upset if residents turn the call light back on. The group also agreed that call lights are frequently on the floor or out of reach. They reported that staff have personal conversations that can be overheard, talk about other residents or their own personal lives, and talk to each other rather than to the resident while providing care, and that staff sometimes visit in rooms instead of completing tasks timely. A family member stated she has had to call the facility to get help for her brother, who needs suctioning and cannot reach his call light, particularly on weekends or after 7:00 p.m. Another resident with chronic respiratory failure, ventilator dependence, muscular dystrophy, and limited use of his hands reported that his press-pad call light, designed to be activated by his head, is sometimes out of reach, forcing him to yell for help. The unit manager stated that call lights should be answered as soon as they go off and should be clipped within residents’ reach, indicating a discrepancy between facility expectations and observed practice.
Failure to Provide and Document ADL and Hygiene Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL and hygiene care, including bathing, nail care, shaving, and personal hygiene, for multiple dependent residents. One resident with metabolic encephalopathy, dementia, muscle weakness, and difficulty walking had long, broken, and jagged fingernails and facial hair extending beyond the goatee style he preferred. His MDS showed moderately impaired cognition and a need for substantial to maximal assistance with bathing and dressing and partial to moderate assistance with personal hygiene. His shower schedule showed only three showers documented over a 30‑day period, and there was no documentation of nail care or refusals of nail care, nor any care plan focus addressing refusals of care. Another resident with bilateral above‑knee amputations, diabetes, cognitive communicative deficit, and end‑stage renal disease on dialysis was observed in a room with a pervasive, rank odor that intensified near the resident. The resident required moderate to total assistance with ADLs and had a care plan calling for two‑person total assist for bathing. The bathing task record showed missed or undocumented scheduled baths and documented refusals on some days, but there was no progress note documentation of reapproach attempts after refusals or explanations for why bathing was not completed on specific dates. The DON attributed the odor to a recent UTI and stated the room would be cleaned, but the record showed only antibiotic courses and did not document hygiene interventions related to the odor. A ventilator‑dependent resident with severe cognitive impairment and total dependence for ADLs was observed with long, dark chin hairs and dark, unknown material under the fingernails. The care plan addressed ADL self‑care deficits and nail trimming behavior but did not include any focus or intervention for chin hair care. Another ventilator‑dependent resident, fully dependent for ADLs, was observed with dry, cracked lips, dried substance around the mouth and cheek, brownish areas on pillow and blankets, and mucous in the corners of both eyes, with similar findings of dried and moist mucous around the mouth on a later observation. The DON acknowledged this lack of hygiene was not acceptable. A resident with heart disease, oxygen dependence, stroke with dysphagia and aphasia, and right‑sided hemiplegia and hemiparalysis, who required moderate to total assistance for most ADLs, was observed with long, greasy hair containing visible chunks of an unknown substance and a long, unkempt beard, despite stating a preference to be shaved and an inability to shave independently. The resident’s right hand was flaccid and clenched in a fist, with long, unkempt fingernails digging into the palm, and the resident reported hand pain from the nails. The care plan called for extensive assist with personal hygiene but did not prevent this condition. Another resident with a history of cerebral infarction, cognitive communication deficit, and acute respiratory distress syndrome, requiring extensive assistance for personal hygiene, was observed with long fingernails. This resident reported disliking the nail length, stated they had asked staff to cut their nails without the request being fulfilled, and that staff did not offer nail care; the EMR contained no documentation of nail care being completed. Across these residents, surveyors found repeated failures to provide scheduled bathing, nail trimming, shaving, and routine hygiene, as well as failures to document refusals and to incorporate refusals and specific grooming needs into care plans. Observations included offensive odors, visibly unclean or unkempt hair and beards, long and jagged fingernails (sometimes causing discomfort), dried secretions on the face, and soiled linens. The records lacked consistent documentation of ADL care completion, reasons for missed care, or follow‑up after refusals, demonstrating that the facility did not implement and operationalize procedures to ensure dependent residents received necessary ADL and hygiene care.
Failure to Assess, Obtain Orders, and Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease, dependence on renal dialysis, gastrostomy feeding, difficulty walking, and muscle weakness, was observed in bed with a padded full side rail in place. The resident was restless and appeared to be attempting to get out of bed, with the side rail preventing a fall. The bed was in the lowest position and a floormat was placed on the floor, but there was no documentation or evidence of appropriate assessment or authorization for the use of the side rail. Review of the resident's electronic medical record revealed the absence of a care plan addressing the use of side rails, no mention of side rails in the fall prevention care plan, and no informed consent or assessment for side rail use. Additionally, there were no initial entrapment measurements or grids for the bed/side rails, and no physician orders authorizing the use of side rails. Interviews with facility staff, including the DON and Unit Manager, confirmed that these required steps were not completed for this resident. Facility policy requires that side rails, considered a form of physical restraint when they restrict movement and cannot be easily removed by the resident, must only be used after a written physician order, informed consent, and a thorough assessment. The policy also mandates documentation of the medical reason for side rail use, compatibility checks, entrapment measurements, and inclusion in the resident's care plan. None of these procedures were followed for the resident in question, resulting in the cited deficiency.
Failure to Implement Enhanced Barrier Precautions and Provide PPE
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to the care plans for two residents who were at high risk for infection transmission due to their medical conditions and devices. For one resident with end-stage renal disease, a gastrostomy, and a hemodialysis port, the care plan required the use of gowns and gloves during high-contact care activities and the posting of EBP signage to alert staff and visitors. However, during observation, there was no EBP signage posted inside or outside the resident's room, and no personal protective equipment (PPE) was available in the room or nearby hallway. The nurse interviewed was unaware of the proper location for PPE and admitted to retrieving PPE from other residents' rooms, which was not in accordance with protocol. The Infection Control Nurse confirmed that signage and PPE should have been present and accessible as per the care plan. Another resident with a history of traumatic brain injury, chronic stage IV pressure ulcer, thoracic spine wound infection, and an indwelling urinary catheter also required EBP per the care plan and physician orders. Observations revealed that there was no EBP signage posted for this resident, and the available PPE in the room was insufficient, consisting of only a couple of gowns. The nurse caring for this resident was unable to locate the required signage and acknowledged that it should have been present. The resident's medical records confirmed recent hospitalization for wound infection and ongoing orders for EBP during high-contact care activities. Facility policy required the use of isolation signs to alert staff, family, and visitors of transmission-based precautions, and specified the use of gowns and gloves for high-contact care activities for residents with certain risk factors. Despite these policies and individualized care plans, the facility did not ensure that EBP signage was posted and that adequate PPE was available and accessible for staff, resulting in a failure to follow established infection prevention and control protocols for the residents reviewed.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Prevent and Address Constipation in Two Residents
Penalty
Summary
The facility failed to implement adequate measures to prevent constipation for two residents who were reviewed for this issue. Both residents had complex medical histories, including diagnoses such as diabetes, end-stage renal disease, renal dialysis, cardiac arrest, seizures, and feeding tubes, and required assistance with all care. Documentation showed that both residents experienced multiple episodes of constipation, with extended periods of no bowel movements, sometimes lasting up to ten days. During these periods, there were also documented episodes of emesis, restlessness, combativeness, and resistance to care. For one resident, the care plan included monitoring for no bowel movement in three days and administering medications as ordered. However, records indicated that there were several instances where the resident went longer than three days without a bowel movement, and interventions were not consistently documented or implemented in a timely manner. The resident experienced repeated episodes of emesis and behavioral changes during these periods of constipation. Additionally, the resident had a fall during a time when constipation was present and had received interventions for bowel elimination. The second resident also had a care plan to observe for no bowel movement in three days and to administer medications as ordered. This resident experienced multiple episodes of constipation, with several periods of four or more consecutive days without a bowel movement. The resident received interventions such as Polyethylene glycol and Bisacodyl suppositories, but these were not always administered according to the facility's bowel protocol. The resident also experienced falls during periods of constipation. Interviews with nursing staff and the DON confirmed that the facility's bowel protocol was not always followed as intended, and that both residents had patterns of repeated constipation that were not adequately addressed.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who was cognitively intact and had a history of cerebrovascular disease, hypertension, apnea, and peripheral vascular disease, experienced unusual fatigue, refused breakfast, and would not get out of bed or speak as usual. Medical interventions were initiated, including oxygen therapy, CPAP, IV fluids, and administration of Narcan, with the provider and nurse manager involved in the resident's care. Despite these significant changes and interventions, there was no documentation that the resident's family was notified at the time of the change. Interviews with facility staff revealed that the nurse manager assumed the floor nurse would notify the family, but could not find any documentation to confirm this. The nurse who provided care during the initial change stated that she attempted to call the resident's daughter but only reached voicemail and did not document the attempt or pass the information to the oncoming nurse. The nurse who took over the next shift believed the family had already been notified and only contacted them at the end of her shift, at which point the family expressed upset at not being informed sooner about the resident's condition and interventions. The facility's policy requires prompt notification of the resident's representative in the event of significant changes in condition, including the initiation of new treatments or clinical complications. In this case, the responsible party notification section in the electronic medical record was left blank, and staff interviews confirmed that the required notification did not occur in a timely manner, resulting in the family not being informed of the resident's change in condition until the following day.
Neglect and Abuse of Residents by Nurse Aide
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically involving two residents. One resident, who was dependent on a ventilator and required significant assistance with activities of daily living, was left unattended and in a soiled state for over two hours during the midnight shift. The resident's call light was ignored by a nurse aide, who expressed that her foot hurt and she was tired of responding to the call light. This neglect led to the resident feeling disrespected, anxious, and expressing suicidal thoughts. The resident's wife had to intervene by calling the facility multiple times to ensure her husband received the necessary care. Another resident, who also had respiratory needs and was dependent on assistance for daily activities, experienced neglect when the same nurse aide refused to assist with oral secretions, stating it was not her job. The aide also used inappropriate language and displayed a lack of professionalism, which made the resident feel uncomfortable and intimidated. The resident had to swallow secretions due to the lack of assistance and felt stressed by the aide's behavior. The facility's policies on abuse, neglect, and maintaining resident dignity were not followed, as evidenced by the staff's failure to respond to call lights promptly and provide necessary care. The social services staff did not assess or refer the first resident for psychological evaluation despite the resident's expressed distress and suicidal thoughts. The care plans for both residents were not adhered to, contributing to the neglect and abuse experienced by the residents.
Sanitation and Equipment Failures in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a tour with Registered Dietitians. The inspection revealed debris inside the handles of the reach-in refrigerator, dried food residue and burnt particles on the toaster, and a speaker placed atop clean dishware. Additionally, wet sheet pans were found on a storage rack meant for dry items, and the kitchen floors were soiled with debris and dried substances. The ice machine's bottom lip yielded a black residue when wiped, and the walk-in cooler had a dusty fan cover and expired food items. The facility's dishwasher was not reaching the required sanitization temperatures, with the temperature gauge failing to move beyond 140 degrees during multiple cycles, despite the requirement for a wash temperature of 150-165 degrees. It was noted that using the sprayer simultaneously with the dishwasher could prevent the water from reaching the necessary temperature. The cleaning logs showed numerous blanks, indicating that daily cleaning tasks were not being completed as required, with several areas such as floors, trash cans, and equipment not being cleaned. The facility's cleaning schedule from late December to early January showed that many deep cleaning tasks were not completed, and there was no coverage when the porter responsible for these tasks was absent. The PM Diet Aide and PM Cook also failed to complete their cleaning tasks during their shifts. The Senior Maintenance Director reported a possible supply and demand issue with the boilers, and a contracted company was addressing a malfunctioning stage controller. The Dietary Manager acknowledged the issues and noted that the dishwasher gauge had been replaced, restoring proper temperature function.
Failure to Timely Act on Influenza Outbreak
Penalty
Summary
The facility failed to act promptly on positive influenza laboratory results and did not operationalize policies and procedures for an influenza outbreak involving two residents. During a Resident Council meeting, two residents who tested positive for influenza attended without masks, exposing other residents. The facility staff, including the Director of Nursing (DON) and Infection Preventionist, acknowledged that these residents should not have been invited to the meeting and that alternative arrangements could have been made to address their concerns. The residents had shown symptoms of influenza, including high temperatures and cough, but were not placed on transmission-based precautions until several days after the positive test results were received. The facility's Infection Control Preventionist was unaware of the positive results until two days after they were faxed to the facility. This delay in receiving and acting on the test results prevented the timely initiation of precautions, facility-wide testing, and acquisition of prophylactic medication for residents. The facility's policy required transmission-based precautions for residents suspected or confirmed to have infectious diseases, but these were not implemented in a timely manner. The residents continued to participate in communal activities despite being on droplet precautions, and the facility did not offer alternative activities in their rooms. The lack of monitoring of the fax machine for pending laboratory results contributed to the delay in initiating necessary precautions and interventions.
Inadequate Activities Program Fails to Meet Resident Needs
Penalty
Summary
The facility failed to provide an activities program that met the interests and needs of its residents, resulting in a monotonous and unoriginal schedule. During a Resident Council meeting, nine residents expressed their dissatisfaction with the current activities, citing that they were boring, poorly organized, and repetitive. They also noted that the activities did not cater to the interests of cognitively intact residents and were often gender-biased, with prizes and activities skewed towards women. Additionally, the residents were frustrated with the lack of space for specialty wheelchairs on the bus for outings, which limited participation to the same group of residents each time. A review of the Resident Council notes from April 2024 to December 2024 showed low attendance, with some months having only one or two residents attending, and one month with no attendees. The activity calendars from July 2024 to January 2025 revealed a lack of variety, with many activities being repeated each month. For example, Sundays consistently featured the same schedule, and many weekdays had identical activities across different months. The Activities Director admitted to copying and pasting activities from month to month without much variation and did not have a substantial response when questioned about the lack of resident-specific programming. The Activities Director also acknowledged that the facility's bus could not accommodate more than one resident with a specialty wheelchair, and the same residents typically attended outings. Despite recognizing the gender bias in BINGO prizes, the director had not taken steps to gather input from residents on desired items. The facility's policy on activities emphasized the importance of designing programs to meet the interests and well-being of residents, but the current programming did not reflect these goals. The Activities Director's job description also highlighted the need for a comprehensive assessment to develop meaningful activities, which was not being fulfilled.
Deficiencies in Cleanliness and Safety in LTC Facility
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, as evidenced by multiple observations of soiled privacy curtains, improperly stored respiratory equipment, and unclean common areas. Privacy curtains in several rooms were noted to have stains of varying colors, and the residents were unable to recall when they were last laundered. The Laundry/Housekeeping Manager confirmed that some curtains could be laundered while others needed to be discarded, but the housekeeping routine did not include checking the privacy curtains. In the common area/dining room on the 300-Hall, wheelchairs and Geri chairs were stored with visible debris and stains, and a walker was found filthy with rips in the seat cushion. Residents' call lights were not within reach, posing a risk to their safety. For instance, a resident with severe cognitive impairment was observed struggling to reach her call light, which was found on the floor without a clip to secure it. Another resident was found eating alone with food debris scattered on her chest and bed, and her call light and TV remote were also on the floor. Additionally, respiratory equipment such as nebulizers and CPAP machines were not stored properly, with some found next to unsanitary items like urinals. The equipment lacked proper labeling and dating, indicating a lapse in infection control practices. The facility's Infection Control Preventionist acknowledged the improper storage and labeling of personal items like wash basins and denture cups, which were found without resident identification. The Maintenance Director was unaware of a ceiling tile issue causing a draft in a shared bathroom, highlighting a communication gap in reporting maintenance concerns.
Failure to Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive activity care plan for a resident, resulting in the potential for lack of meaningful activities and decreased quality of life. The resident, who was observed in their room wearing a hospital gown and receiving mechanical ventilation via a tracheostomy, was able to communicate by mouthing words and indicated they could write or type. However, no method for written communication was present in the room. The resident expressed a desire to participate in activities outside their room, such as going to the small lounge to read or do puzzles, but reported that staff were not responsive to call lights or requests for assistance, and there was insufficient staff to facilitate their participation in these activities. A review of the resident's electronic medical record revealed that they did not have a care plan in place for activities, despite being cognitively intact and having specific activity preferences. The Director of Nursing confirmed the absence of an activity care plan for the resident and was unable to provide an explanation for this oversight. The facility's policy requires that each resident's interests and needs be assessed routinely and incorporated into a care plan, which was not adhered to in this case.
Delay in Treatment for Resident with Pneumonia
Penalty
Summary
The facility failed to provide timely treatment for a resident who experienced a change in condition, resulting in a potential exacerbation of pneumonia and sepsis. The resident, who had a history of chronic obstructive pulmonary disease, influenza, and sepsis, was admitted to the facility and later readmitted with these diagnoses. The resident began exhibiting symptoms such as a cough and elevated temperatures, which were documented in the progress notes. Despite these symptoms, there was a delay in obtaining and acting upon laboratory results and in administering appropriate medication. The resident's medical record indicated that a chest x-ray was ordered after the resident showed signs of a high temperature and wheezing. However, there was a delay in receiving and reviewing the results of a respiratory panel, which eventually revealed the presence of influenza and Staphylococcus aureus. The facility staff did not become aware of these results until several days after they were faxed to the facility. Additionally, there was a delay in the administration of antibiotics due to an allergy to the initially prescribed medication, Levaquin, and a subsequent delay in ordering an alternative antibiotic, Doxycycline. Interviews with the Infection Control Preventionist and the Director of Nursing revealed that the facility did not promptly act on the laboratory results or the resident's need for a change in medication. The Director of Nursing acknowledged the delay in treatment and the failure to promptly address the resident's condition. This deficiency highlights a lapse in the facility's processes for managing changes in residents' conditions and ensuring timely medical interventions.
Failure to Document and Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who returned from the emergency room with a urinary catheter. The resident, who is cognitively intact but dependent on staff for daily care, was observed with a catheter drainage bag upon return from the emergency room. However, there was no documentation in the resident's medical record indicating the presence of the catheter, nor were there any physician orders, nursing notes, or care plans addressing the catheter. The facility's policy requires catheter care to be provided in accordance with current clinical standards, including regular emptying and monitoring, but these procedures were not documented or followed. The deficiency was further highlighted when a CNA reported providing catheter care without any charting prompts indicating the presence of a catheter. The Unit Manager was unaware of the catheter and could not find any additional information or documentation regarding its placement or removal. This lack of documentation and communication resulted in the resident not receiving the necessary assessment, monitoring, and ongoing care for the urinary catheter, as required by the facility's policy.
Improper Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure proper administration of enteral tube feeding for a resident, resulting in insufficient head of bed elevation during tube feeding administration. The resident, who was receiving mechanical ventilation via a tracheostomy and tube feeding via pump, was observed with the head of their bed at a 24-degree angle, which is below the minimum 30-degree elevation recommended by the Director of Nursing (DON) and professional standards of practice. The resident did not have a care plan or Health Care Provider (HCP) order specifying the required degree of head elevation during tube feeding. The resident involved had a complex medical history, including gastrostomy, end-stage renal disease with dialysis dependence, heart disease, tracheostomy, respiratory failure with ventilator dependence, and pneumonia. The resident was moderately cognitively impaired and required maximum to total assistance for Activities of Daily Living (ADLs). The facility's policy on feeding tubes did not specify the necessary head of bed elevation during tube feeding, contributing to the deficiency observed.
Failure to Flush PICC Line After IV Medication Administration
Penalty
Summary
The facility failed to properly manage and care for a Peripherally Inserted Central Catheter (PICC) line for a resident, resulting in a deficiency. During an observation, a Registered Nurse (RN) was found to have not flushed the PICC line after administering IV Cefepime, an antibiotic, to the resident. The medication was administered the previous day, and the IV pump was found turned off with an empty bag still connected to the resident's PICC line. The RN acknowledged that PICC lines should be flushed after medication administration but did not provide an explanation for the oversight. The resident involved had a complex medical history, including Amyotrophic Lateral Sclerosis (ALS), anarthria, a tracheostomy, and ventilator dependence, and was severely cognitively impaired. The resident's care plan did not include monitoring and care for the PICC line. The Director of Nursing (DON) confirmed that PICC lines should be flushed following IV medication administration. The facility's policy on flushing guidelines for peripheral venous catheters was reviewed, which stated that IV catheters should be flushed before and after each infusion.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident, resulting in the non-administration of prescribed medications Bumetanide and Spironolactone. The resident, who had multiple serious health conditions including congestive heart failure and chronic obstructive pulmonary disease, was not given Bumetanide on several occasions and Spironolactone on multiple days as the medications were not available. The Medication Administration Record (MAR) indicated that the medications were on order from the pharmacy, but there was no documentation of communication with the pharmacy or the resident's practitioner regarding the missed doses. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the issue until the survey. The DON acknowledged that the medications should have been obtained from the back-up supply if available, and the pharmacy should have been contacted for follow-up. The facility's back-up medication list confirmed that Spironolactone was available, but it was not utilized. Additionally, there was no facility policy provided regarding medication administration and acquisition, which was requested during the survey.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the practitioner for a resident, resulting in significant medication errors. The resident, who had multiple diagnoses including congestive heart failure and acute kidney failure, was not administered Bumetanide and Spironolactone on several occasions. The Medication Administration Record (MAR) indicated that Bumetanide was not given on six different days, and Spironolactone was not administered on six different days as well. The progress notes consistently cited waiting on medication from the pharmacy as the reason for non-administration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the issue until it was brought to their attention. The DON acknowledged that the nurse should have contacted the provider and arranged for an alternative until the medication arrived. There was no documentation in the medical record that the practitioner had been notified of the missed doses, and the practitioner confirmed that they had not received any communication regarding the missed medications. The lack of communication and documentation led to the resident not receiving critical diuretic medications, which could potentially exacerbate their medical conditions.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to ensure that immunizations were reviewed and offered to a resident, resulting in a deficiency related to infection control. During a survey, it was found that a resident, who had been diagnosed with influenza, did not have documentation of being offered or receiving the influenza vaccine, nor any record of refusal. The resident's medical history included significant health issues such as congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, and dependence on supplemental oxygen, which could increase the risk of complications from influenza. The Infection Control Preventionist (ICP) acknowledged the lack of immunization information in the resident's medical record and was unable to find any documentation of the resident being offered or refusing vaccinations. The ICP noted that the resident's name did not appear on the audit report, which was supposed to include all residents. Facility policies require that residents be offered influenza vaccinations annually and that documentation should reflect whether the resident received the immunization or refused it. However, this process was not followed for the resident in question, leading to the deficiency.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure dignified and respectful care for several residents, leading to multiple deficiencies. Resident #61, who is dependent on a ventilator and has a tracheostomy, experienced significant delays in staff response to call lights, resulting in unnecessary incontinence and feelings of embarrassment and frustration. The resident also reported discourteous and unprofessional behavior from staff, including a nurse accusing them of disconnecting their ventilator tubing for attention. Additionally, the resident lacked access to adaptive communication devices, such as a whiteboard or paper and pen, which hindered their ability to communicate effectively with staff. Resident #39, who has a history of stroke and dysphagia, was observed eating alone in their room without supervision, despite having swallowing precautions posted on the wall. The resident was not provided with a clothing protector and was found with food on their chest and bed. The care plan for Resident #39 indicated the need for supervision during meals, but no staff was present to assist or monitor the resident while eating, which is contrary to the care plan requirements. In the dining area, several residents were observed using towels instead of proper shirt protectors, which failed to adequately protect their clothing from food spills. This was attributed to a shortage of shirt protectors due to issues with the facility's laundry service. Additionally, Resident #4 was exposed during a transfer to a shower chair, as the privacy curtain was not closed, and the door to the room did not stay shut, compromising the resident's dignity and privacy. These observations highlight the facility's failure to maintain resident dignity and privacy as per their policy.
Failure to Provide Timely ADL Care and Supervision
Penalty
Summary
The facility failed to provide necessary services for timely response and assistance with Activities of Daily Living (ADL) care for three residents, resulting in discomfort and feelings of frustration and embarrassment. Resident #43 was found in bed with a strong odor of urine and bowel movement, indicating a lack of incontinence care since the previous night. The resident's bed was stuck in a high-seated position, causing neck and back pain, and staff failed to address the issue or provide care. The bed was later found to be unplugged, and once reconnected, the resident expressed increased comfort. Resident #61 reported long wait times for call light responses, leading to incontinence due to delayed assistance with toileting. The resident, who was dependent on a ventilator, expressed embarrassment and frustration over the situation. Despite having a bedside commode, the resident was unable to use it without assistance, and staff were observed turning off the call light without addressing the resident's needs. Resident #39, who had swallowing precautions due to a history of stroke, was observed eating alone without supervision or assistance, resulting in food spillage. The resident's care plan required supervision during meals, but no staff were present to assist or monitor the resident while eating. This lack of supervision posed a risk given the resident's swallowing difficulties and need for assistance with meal setup.
Failure to Implement Safety and Supervision Interventions
Penalty
Summary
The facility failed to implement care-planned interventions for safety and supervision for three residents, leading to potential and actual harm. Resident #4, who has multiple sclerosis, dementia, and Alzheimer's disease, was transferred using a mechanical lift by a single CNA, contrary to the care plan that required two-person assistance. The CNA admitted to transferring the resident alone due to being behind in work and lack of available staff, which was against facility policy. Resident #35, with severe cognitive impairment and multiple physical disabilities, was found without a call light within reach and with only one fall mat in place, despite care plan interventions requiring bilateral floor mats and the call light to be accessible. The resident had previously been observed sliding off the bed, and the care plan included interventions to prevent falls, which were not fully implemented. Resident #39, who has hemiplegia and dysphagia, was observed eating alone without supervision, despite care plan requirements for supervision during meals due to swallowing precautions. The resident's care plan specified the need for assistance with meal setup and monitoring while eating, which was not provided, as no staff were present in the hallway to assist or supervise the resident during the meal.
Failure to Dispose and Document Controlled Substances
Penalty
Summary
The facility failed to promptly dispose of 24 pills of oxycodone and maintain accurate and legible controlled medication reconciliation records for a resident. During an observation of the Vent Medication Cart, it was found that the Controlled Substance Log for Oxycodone IR 5 MG Tab had disorganized entries with multiple witnessed initials that were difficult to match to specific rows. The log indicated that the resident was administered oxycodone on a specific date, but there were no nurse initials, and the blister pack showed a missing pill with a circled bubble. The resident's medical records revealed that the oxycodone order had been discontinued months prior, and there was no documentation of administration on the date in question. Further investigation with the Director of Nursing and Unit Manager revealed that the pill was intended to be wasted due to damage to the blister pack, but this was not properly documented. The disorganization of the narcotic form made it unclear whether the nurse signatures corresponded to the correct entries. The facility's policy on controlled substances requires accurate inventory and proper documentation of disposal, which was not adhered to in this case. The resident involved had a medical history including respiratory failure, end-stage renal disease, atrial fibrillation, hypotension, and polyneuropathy.
Failure to Prevent Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse involving a resident with paranoid schizophrenia, hypothyroidism, heart failure, anxiety, depression, and intellectual disabilities. The resident, who had moderate cognitive decline and required assistance with all care, was subjected to verbally abusive language by a staff member. The incident occurred in the main dining room after an activity, where the staff member told the resident to "shut your mouth," which was overheard by other staff members. The staff member involved had a history of inappropriate verbal interactions with co-workers, having been reprimanded three times prior to this incident. Despite these previous incidents, the staff member continued to work at the facility until the verbal abuse towards the resident occurred. The facility's policy on abuse, neglect, and exploitation, which was in place to protect residents' health, welfare, and rights, was not effectively implemented to prevent this incident.
Deficiencies in Resident Safety and Care Management
Penalty
Summary
The facility failed to adequately assess, monitor, and implement interventions to prevent an overdose for a resident with a long-standing history of polysubstance abuse. The resident, who had been admitted with a history of substance abuse and various medical conditions, was prescribed a fentanyl patch for pain management. However, the facility did not inform the prescribing practitioners of the resident's substance abuse history, nor did they obtain informed consent from the resident's guardian for the administration of fentanyl. The patch was applied in an accessible area, leading to the resident ingesting it and experiencing an overdose, which required multiple doses of Narcan to reverse. Additionally, the facility failed to ensure a safe environment and adequate supervision to prevent falls for two residents. One resident fell while taking a shower, resulting in minor injuries, but the incident report was incomplete, lacking details about the nursing assistant's location during the fall. Another resident, who was quadriplegic and unable to move independently, was found on the floor after an unwitnessed fall. The facility did not conduct a thorough investigation or update the care plan to address the root cause of the fall, which was attributed to aggressive coughing. The facility's failure to conduct complete investigations and implement appropriate interventions for both residents highlights deficiencies in ensuring resident safety and preventing accidents. The lack of documentation and communication regarding the residents' conditions and care needs contributed to these incidents, resulting in potential harm and a decline in the residents' medical conditions.
Improper PPE Use During PEG Tube Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, leading to a potential risk of contamination and infection spread. During an observation, Nurse D was seen performing PEG tube site care for a resident who was on Enhanced Barrier Precaution due to tracheostomy and gastrostomy status. Nurse D did not properly secure her gown, as it was not tied at the neck and the waist belt was not securely fastened. During the procedure, the gown tore and fell off her shoulders, exposing her clothing and potentially contaminating the care area. The resident involved was admitted with multiple complex medical conditions, including quadriplegia, tracheostomy, gastrostomy, and chronic respiratory failure with hypoxia. The resident was bedridden, had contractures, and was unable to communicate or request assistance, relying entirely on staff for care. The facility's policy on PPE, which mandates the use of appropriate protective gear to prevent pathogen transmission, was not adhered to during this incident, as evidenced by the improper gowning technique observed.
Inconsistent Pain Management for Resident with Ankle Fracture
Penalty
Summary
The facility failed to consistently complete pain assessments and administer medication as ordered for a resident with an acute displaced fracture of the right ankle. The resident, who was admitted for short-term skilled nursing and rehabilitation services, had a history of cellulitis and heart failure and had fallen at home prior to admission. Despite having intact cognition, the resident reported worsening pain after admission, which was confirmed by an x-ray showing a right ankle fracture. However, the resident did not consistently receive their prescribed pain medication, leading to prolonged periods of unmanaged pain. The resident's electronic medical record revealed inconsistencies in pain assessments and medication administration. On several occasions, the resident's pain levels were documented as high, yet there were significant delays in administering the next dose of pain medication. For instance, on one day, the resident reported a pain level of 8/10 in the morning but did not receive medication until nearly 12 hours later. Similarly, on another day, the resident reported a pain level of 8/10 in the evening, but there was no follow-up assessment or medication administration for approximately 18 hours. Interviews with the Director of Nursing (DON) indicated an awareness of the concerns but did not provide a satisfactory explanation for the inconsistencies. The facility's pain management policy emphasized the importance of systematic recognition, assessment, treatment, and monitoring of pain, yet these protocols were not followed in the case of this resident. The failure to adhere to the facility's pain management policy resulted in inadequate pain control for the resident, as evidenced by the documented gaps in pain assessment and medication administration.
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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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