Medilodge Of Grand Rapids
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 2000 Leonard Ne, Grand Rapids, Michigan 49505
- CMS Provider Number
- 235038
- Inspections on file
- 31
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Medilodge Of Grand Rapids during CMS and state inspections, most recent first.
A hospice resident with heart disease and lung cancer, who was cognitively intact and had clearly chosen DNR status, had that wish documented by hospice and on facility DNR forms completed at admission and again several days later. The facility lost or could not locate the initial DNR paperwork, and when a new DNR form was completed and sent to the physician, the signed form was returned but remained in the DON’s inaccessible email inbox and was never entered into the EHR. Because the resident’s orders still showed FULL CODE, an LPN and other staff initiated CPR, used an AED, and called EMS when the resident was found pulseless, leading to extensive resuscitative efforts that directly contradicted the resident’s documented end-of-life wishes.
A hospice resident with a history of atherosclerotic heart disease and unstable angina, who was cognitively independent, requested and signed DNR paperwork, but the facility failed to complete and implement advance directive and DNR documentation at admission and did not update the EMR code status from "Full Code" after the physician signed the DNR. The DON received the signed DNR via email but did not access it, and no other staff had access to that inbox, so the resident’s record continued to show "Full Code." When the resident was later found unresponsive, an LPN verified the code status in the orders as "Full Code" and staff initiated CPR, used an AED, and EMS provided advanced resuscitative measures, contrary to the resident’s expressed DNR wishes, as also reported by the family and hospice documentation.
A resident with a history of cerebral infarction and other conditions exhibited signs of a stroke, but the LTC facility staff failed to recognize and act on the change in condition. Despite being aware of the symptoms, the staff did not transfer the resident to the emergency room until the family intervened, leading to a 27-day hospitalization. The facility's lack of communication, documentation, and adherence to protocols contributed to the deficiency.
A resident with moderate cognitive impairment and a history of falls experienced multiple falls due to inadequate supervision in an LTC facility. Despite a care plan to reduce injury risk, the resident fell several times, resulting in a head laceration and hematoma. Interviews revealed that the facility was understaffed, unable to provide the necessary 1:1 supervision, and failed to meet the resident's supervision needs, leading to repeated falls and injuries.
The facility failed to ensure proper PPE use and cleaning of shared equipment, risking infection spread. Two residents under enhanced barrier precautions were not provided appropriate care, as staff, including the DON, did not wear required PPE during care activities. Shared equipment was also found heavily soiled, indicating poor cleaning practices. Staff interviews revealed a lack of understanding and implementation of infection control measures.
A long-term care facility failed to provide sufficient staffing, resulting in falls and unmet care needs for residents. One resident, who was at risk for falls, experienced multiple unwitnessed falls due to inadequate supervision, leading to head injuries and emergency room visits. Another resident was unable to receive proper grooming and assistance with daily activities due to staffing shortages. Staff and family members reported concerns about the lack of supervision and care, highlighting the impact of insufficient staffing on resident safety and well-being.
The facility failed to maintain dignity and privacy for two residents. A resident with cerebral palsy and other conditions was not shaved daily as per her care plan, leading to concerns about her appearance. Another resident was transferred with a mechanical lift while her room door was open, compromising her privacy. These actions were contrary to the facility's policy on resident dignity.
A resident with a history of cerebral infarction and other conditions experienced a change in condition, including decreased consciousness, which was not communicated to the family by the facility staff. Despite the facility's policy requiring notification of significant changes, the family only learned of the situation upon visiting the resident, resulting in a delay in transferring the resident to the emergency room for evaluation.
A resident received wound care and compression stockings without physician orders, despite having a care plan indicating a risk for skin integrity issues. The resident had a cut on their hand and was observed receiving care without proper medical direction. The DON confirmed the absence of orders, noting the resident's spouse requested the stockings without medical necessity.
A resident with dysphagia was given the wrong meal tray, leading to choking and death. A new CNA, unsupervised and unfamiliar with residents, delivered a regular diet instead of the prescribed pureed diet. The facility was short-staffed, and the CNA lacked access to verify diet orders, contributing to the incident.
A resident with dysphagia and other conditions was mistakenly served a regular meal tray, leading to a choking incident and subsequent death. Despite attempts to resuscitate, the resident did not survive. The facility failed to report the incident to the State Agency, as advised by corporate, believing it was the hospital's responsibility.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illness spread. Improper cooling of breakfast sausage, open raw hamburgers in the freezer, and encrusted saucepans were observed. The dish machine's wash temperature was below the required minimum, and food items lacked proper date labeling, violating food safety protocols.
The facility failed to honor resident privacy and dignity, as reported by eight residents during a Resident Council meeting. Residents felt frustrated and disrespected due to staff entering rooms without knocking and being distracted by phones during the third shift. Previous concerns about staff not introducing themselves were also noted. The Activities Director was unaware of recent issues, and the Nursing Home Administrator believed improvements had been made.
The facility failed to resolve grievances reported in Resident Council Meetings, as seven residents expressed ongoing issues with showers, cold food, and call light response times. Despite the Activities Director's awareness and communication of these concerns to department heads, the facility did not effectively address them, leading to unresolved issues over several months.
The facility failed to maintain adequate supplies of bath linens and incontinence products, leading to unsanitary conditions and frustration among residents. A resident with multiple sclerosis and another with heart failure reported frequent shortages of washcloths and preferred briefs, confirmed by staff who resorted to makeshift solutions. Observations revealed a lack of washcloths and unsanitary conditions in common areas, with management acknowledging the issue but failing to resolve it.
The facility failed to provide routine showers for several residents, leading to frustration and embarrassment. A resident with multiple sclerosis missed 7 out of 25 scheduled showers, while another missed 10 out of 24. A cognitively impaired resident was observed with poor hygiene, missing 11 out of 24 showers. A cognitively intact resident reported going 11 days without a shower. Staffing shortages were cited as a reason for missed showers, and the issue was raised in a resident council meeting.
The facility failed to provide adequate staffing, resulting in long wait times for resident assistance, missed showers, and insufficient supervision. Residents with conditions like multiple sclerosis and cognitive impairments experienced delays in daily activities due to staffing shortages. Staff confirmed the lack of sufficient CNAs and the challenges in providing timely care. Despite concerns from residents and staff, the facility had not effectively addressed the staffing issues.
The facility failed to serve food at palatable temperatures, as observed during a survey. Test trays showed food temperatures below the expected level, and residents consistently reported receiving cold meals and drinks. Despite concerns raised in Resident Council meetings, the issue persisted, affecting residents' dining experiences.
The facility failed to provide nourishing nighttime snacks to eight residents, leading to a potential 13-14 hour gap between dinner and breakfast. Residents reported limited snack options and suspected staff consumption of their snacks. Despite a policy requiring nursing staff to offer and document snacks, issues with availability and variety persisted.
A facility failed to ensure accurate advanced directive information for a resident, whose advance directive indicated no resuscitation, but the EHR listed them as full resuscitation. Staff relied on the EHR for code status, and the error was missed during care planning reviews.
A facility failed to complete a Level II PASARR evaluation for a resident with mental health diagnoses, including schizoaffective disorder and major depressive disorder. The resident's screening indicated the need for further evaluation, but the process was incomplete due to a lack of communication and access issues. The Regional Social Worker completed the screening, but it awaited the medical doctor's review, who was unaware of her responsibility and lacked login credentials.
The facility failed to develop comprehensive care plans for two residents, one with hand stiffness requiring splints and another undergoing dialysis. The first resident needed assistance with splints due to non-compliance, but this was not included in her care plan. The second resident's dialysis care plan was delayed, lacking coordination with the dialysis provider. These oversights resulted in incomplete care plans, potentially affecting the residents' care.
A resident experienced dysuria for two weeks due to a facility's mishandling of a lab specimen, which was sent to the wrong lab following a switch in lab providers. The nursing staff failed to monitor pending lab results, and the resident's reports of pain were not communicated to the provider, resulting in delayed treatment for vulvovaginitis.
A facility failed to reassess a resident's preference for using therapy-recommended hand splints, leading to potential complications. The resident, with a history of hand stiffness and cognitive intactness, needed assistance to apply the splints but reported staff did not remind her. Therapy staff had set a schedule for alternating hand use, but no sign was found in the resident's room, and there was no physician's order or care plan documentation for the splints, contributing to the deficiency.
A resident with an indwelling urinary catheter was at risk for infection due to inadequate catheter care. Despite the presence of dark, sediment-filled urine and a strong odor, the catheter had not been changed since May. Interviews revealed that staff were unaware of the catheter change schedule, and the medical director noted the increased risk of infection due to prolonged catheter use.
A facility failed to provide adequate care for a resident receiving enteral nutrition. The resident, with a history of dysphagia following a stroke, required continuous tube feeding and specific bed elevation. Observations revealed the bed was not elevated as required, and the feeding formula lacked proper labeling. Interviews confirmed these deficiencies, which contradicted the facility's Feeding Tube policy.
A facility failed to obtain physician orders for a resident's oxygen use, leading to potential risks. The resident, admitted with weakness, was observed receiving oxygen without corresponding orders or a care plan. Staff interviews confirmed the absence of a physician's order, and the MD was unaware of the oxygen use.
A resident experienced delayed treatment due to the facility's failure to ensure timely completion of a urinalysis. The urine sample was sent to the wrong lab following a switch in lab providers, leading to confusion among staff. The facility had not provided necessary training on the new lab process, resulting in a lack of tracking and monitoring of lab orders.
The facility failed to implement proper infection control practices, leading to unsanitary conditions and the potential for the spread of infection among residents. A resident with a urinary catheter did not receive care with the required PPE, another resident with psoriatic arthritis had blood-stained linens and soiled skin, and a third resident with a pressure ulcer was assisted without proper PPE. Shared equipment was also found to be heavily soiled and not sanitized between uses.
The facility failed to respect residents' private space, leading to feelings of embarrassment and potential negative psychosocial outcomes for three residents. Incidents included staff entering rooms without proper knocking and exposing residents during personal care activities.
The facility failed to accommodate resident choices and preferences for three residents, leading to issues with hygiene, care routines, and responsiveness. One resident was left in a soiled brief, another did not receive daily bed baths or clean linens, and a third had issues with urinals not being emptied by night staff.
The facility failed to prevent the misappropriation of a resident's narcotic medications when an LPN altered the narcotic count sheet and inadvertently threw away four Oxycodone tablets. The resident, who was cognitively intact and had multiple sclerosis, reported no issues with receiving pain medications. The facility conducted audits and training to ensure compliance with protocols for handling controlled substances.
The facility failed to provide palatable food for three residents, resulting in dissatisfaction with meal quality, portion size, taste, and temperature. Observations and interviews revealed issues such as repetitive menus, cold and unappetizing food, and instances of raw or frozen food being served. The Regional Registered Dietician acknowledged these problems, attributing them to staff turnover and menu planning focused on Assisted Living residents rather than those in Long Term Care.
The facility failed to maintain a clean and sanitary environment, resulting in strong odors and increased infection risk. Residents reported uncleaned floors and overflowing trash cans. Observations confirmed soiled furniture and dirty floors. Housekeeping staff admitted that cleaning was not always completed due to being short-staffed.
Failure to Honor DNR Resulting in Unwanted CPR and Life-Sustaining Measures
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact hospice resident’s clearly expressed wish to be Do Not Resuscitate (DNR), resulting in CPR and other life-sustaining interventions being performed. The resident was admitted on hospice services with diagnoses including atherosclerotic heart disease with unstable angina, lung cancer, heart failure, and a history of malignant neoplasm of the bronchus and lung. Pre-admission hospice documentation faxed to the facility and uploaded into the electronic medical record before admission indicated the resident’s care type as hospice and explicitly listed “DO NOT RESUSCITATE” in the clinical information. The resident’s hospice care plan also stated that the goal was for the resident’s end-of-life wishes to be honored. On the day of admission, the resident, who was documented as cognitively independent and responsible for her own decisions, completed the facility’s DNR form expressing that no one should attempt resuscitation if her heart and breathing stopped. Family members present at admission confirmed that the resident completed and returned the DNR paperwork to the nurse doing the admission, and that hospice had already communicated the resident’s DNR status to the facility. However, the facility later could not locate any advanced directive or DNR forms for the resident during an admission audit. The DON confirmed that consent forms, including advanced directives and DNR, were supposed to be completed on day 1, but for this resident the DNR was not found and was not in place as required. Several days after admission, when the missing DNR was discovered, the DON and an LPN again completed a DNR form with the resident, who remained her own responsible party. This DNR form was signed by the resident and two witnesses and then emailed by the DON to the medical director for physician signature. The physician signed the DNR and returned it electronically to the DON’s individual email inbox approximately seven hours before the resident experienced a code event. The DON, who was not working and was the only person with access to that inbox, did not retrieve the signed DNR, and the resident’s electronic physician orders were never updated from “FULL CODE” to DNR. As a result, when the resident was later found unresponsive on the bathroom floor without a pulse, the LPN checked the physician orders, saw “FULL CODE,” and initiated CPR, used an AED, and called EMS. EMS continued resuscitative efforts, including defibrillation, airway placement, and intraosseous access, until the resident was pronounced deceased. The facility’s own documentation and family interviews confirmed that CPR and other life-sustaining measures were performed despite the resident’s documented and repeatedly communicated wish to be DNR, and that the failure to timely complete, retain, and implement the DNR documentation led directly to the provision of unwanted resuscitative care.
Removal Plan
- Completed a blanket audit of residents to ensure the medical record accurately reflects each resident’s code status and that a signed copy of the advance directive is uploaded into PCC; no concerns or corrections noted.
- Reviewed the CPR and Advanced Directive policy by the NHA and DON and determined it remains appropriate.
- Had the Social Service Director audit all residents to ensure proper code status is in place; no changes required.
- Completed a DON audit of admissions to ensure proper code status is in place for new admissions; no discrepancies noted and no corrections made.
- Reviewed the admission policy and deemed it appropriate.
- Educated all licensed nurses on completing advanced directives paperwork on admission with the designated responsible party and notifying the physician to obtain orders and place into PCC.
- Implemented a process requiring the admitting nurse to meet with the resident/responsible party immediately upon admission to address code status wishes, complete the paperwork, and immediately communicate with the physician to obtain orders for entry into PCC.
- Implemented a process for immediate action on code status documentation: the admitting nurse faxes the document to a preprogrammed fax number that transmits to the provider email; the provider signs and returns via provider phone to facility fax; nurses also call the provider to alert them of the incoming document.
- Initiated weekly DON audits to ensure new admissions’ code status documentation is obtained/completed by the admitting nurse and that facility procedure/policy is followed, continuing until QAPI determines substantial compliance is achieved.
Failure to Implement and Honor Resident DNR Order Resulting in Full Resuscitation
Penalty
Summary
The deficiency involves the facility’s failure to obtain, process, and implement a resident’s advance directive and DNR order in a timely manner, and the subsequent failure to honor the resident’s DNR status during a cardiac arrest. The resident was admitted on hospice services with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris and was cognitively independent, able to make consistent and reasonable decisions. On admission, the facility did not complete consent forms, including advance directives and DNR paperwork, as confirmed by the DON during an admission audit conducted days later. The facility’s own policy required determination of advance directives on admission and completion of a DNR order form signed by the attending physician and resident, to be placed in the front of the medical record and scanned into the electronic record. The DON reported that after discovering the missing consents during the admission audit, she had an LPN meet with the resident to complete the consents, including the DNR form. The resident, who was her own responsible party, signed the facility DNR form in the presence of the DON and the LPN, and the form was later signed by the physician. The DON emailed the DNR form to the medical director for signature and received the signed DNR back in her individual email inbox at 3:37 PM on the day of the code event. However, the DON was not working that day, did not check her email, and no one else had access to that inbox. As a result, the signed DNR form was not retrieved, the resident’s code status in the electronic medical record was not updated from “Full Code” to “Do Not Resuscitate,” and the DNR form was not placed or scanned into the resident’s record prior to the code event. Later that evening, the resident was found unresponsive on the bathroom floor by an LPN, who checked the code status in the physician’s orders and saw it listed as “Full Code.” Based on that information, staff initiated CPR, brought the crash cart and AED, and called EMS. The facility’s Code Blue documentation and EMS records show that CPR, AED use, airway management, administration of epinephrine, IV fluids, and intraosseous access to the tibia were performed in an attempt to resuscitate the resident, and the resident was later pronounced deceased. The resident’s family member reported that the resident had completed DNR paperwork with the admission nurse on the first day of admission and that hospice had sent preadmission screening documents indicating the resident’s wish to be DNR. The family member expressed concern that the resident’s advance directives and end-of-life care were not honored and that the resident underwent a code despite her stated wishes.
Failure to Implement Treatment for Change in Condition
Penalty
Summary
The facility failed to implement appropriate treatment measures when a change in condition was identified for a resident, resulting in an Immediate Jeopardy situation. The resident, who had a history of cerebral infarction due to occlusion, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, exhibited signs and symptoms of a stroke. Despite these symptoms, the facility staff did not recognize the condition as a stroke, leading to a delay in treatment and a subsequent 27-day hospitalization for the resident. On the day of the incident, the resident was noted to have a decreased level of consciousness, was unresponsive, and unable to swallow medications. The nursing staff, including an RN and an ADON, were aware of the change in condition but did not take appropriate action to transfer the resident to the emergency room immediately. The RN did not complete the necessary documentation or notify the family, and the ADON did not document any assessment of the resident's condition. The resident was only sent to the emergency room the following day after the family insisted on it. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's change in condition. The DON and MD were aware of the situation but did not provide specific instructions for monitoring or treatment. The facility's policy on notification of changes was not followed, as the family was not informed of the resident's condition until they visited the facility. The lack of timely intervention and failure to follow established protocols contributed to the resident's prolonged hospitalization and diagnosis of a cerebral infarction.
Removal Plan
- The facility identified that the resident had a change in condition. The resident was transferred to the emergency room for evaluation.
- The facility identified treatment was not implemented for a change in condition for Resident #100.
- The Director of Nursing and/or designee began education of the facility staff on signs and symptoms of a stroke, to include specifically decreased oral intake, unresponsiveness, inability to take medications and decreased level of consciousness. How to seek medical direction and treatment for urgent levels of care. Notification of family of change in condition. Physician/provider notification of change in condition. Documentation of notifications and assessments. How to identify acute changes in condition. No staff will not be permitted to work prior to receiving the education.
- The DON and/or designee completed a chart audit of all residents to determine if any other residents had sustained an acute change of condition. No others were found.
- The QAPI committee had reviewed the change in condition policy and deemed it appropriate.
- The facility had an Ad Hoc QAPI Meeting, including the Medical Director, and deemed this removal plan appropriate.
Inadequate Supervision Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for Resident #102, who was moderately cognitively impaired and had a history of falls. The resident required moderate assistance for transfers and ambulation and had a care plan in place to reduce the risk of injury. Despite this, the resident experienced multiple falls, including one that resulted in a head laceration requiring stitches and a hematoma. The care plan interventions included educating the resident on safety, encouraging the use of a call light, and keeping needed items within reach. However, these measures were insufficient to prevent the resident from attempting to stand and transfer independently, leading to repeated falls. Interviews with staff and family members revealed that the facility was understaffed and unable to provide the level of supervision needed for Resident #102. The resident was known to be impulsive and required constant reminders and monitoring, yet the facility did not have enough staff to provide 1:1 supervision consistently. Staff members reported that the resident often attempted to stand up and fell when left unsupervised, and the facility's staffing levels were inadequate to meet the resident's needs. The Director of Nursing acknowledged the need for frequent checks and supervision but admitted that the facility struggled to provide the necessary level of care. The facility's fall prevention policy stated that each resident should receive care and services according to their level of risk to minimize falls. However, the nursing schedules reviewed for the days when Resident #102 fell showed that the facility was operating with less staff than required for the resident's unit. This lack of adequate staffing and supervision directly contributed to the resident's repeated falls and injuries, highlighting a deficiency in the facility's ability to ensure a safe environment for residents at risk of falls.
Inadequate PPE Use and Equipment Cleaning in LTC Facility
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and proper cleaning of shared equipment, leading to potential infection risks. Resident #100, who had diagnoses including cerebral infarction and epilepsy, was supposed to be under enhanced barrier precautions due to a feeding tube. However, staff, including the Director of Nursing (DON) and Certified Nurse Assistants (CNAs), were observed not wearing gowns as required when providing care or repositioning the resident. Additionally, there was no PPE available in the shower room for Resident #100, and staff were not consistently aware of the need for enhanced precautions. Resident #103, diagnosed with cerebral palsy and muscle contractures, was also under enhanced barrier precautions. Despite this, the DON and a CNA were observed transferring the resident without wearing the required PPE. The CNA admitted to not being fully educated on the precautions, and the DON initially stated PPE was not needed for transfers but later acknowledged it was required. Furthermore, shared equipment like the hoyer lift was not cleaned after use, and other equipment in the facility was found to be heavily soiled, indicating a lack of proper cleaning protocols. Interviews with staff revealed a lack of consistent understanding and implementation of infection control measures. The Staff Development/Infection Control (SD/IC) personnel, who was still in training, confirmed the absence of PPE in certain areas and the need for staff education. The facility provided a certificate for the DON's completion of an infection preventionist training course, but the report highlights ongoing issues with adherence to infection control protocols.
Inadequate Staffing Leads to Falls and Unmet Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to provide adequate care for residents, resulting in multiple incidents of falls and unmet care needs. Resident #102, who was moderately cognitively impaired and at risk for falls, experienced several unwitnessed falls due to inadequate supervision. Despite the care plan indicating the need for constant reminders and monitoring, the facility was understaffed, with only two nurses and three CNAs for 54 residents, which was below the necessary staffing levels. This lack of supervision led to Resident #102 suffering head injuries and requiring emergency room visits. Interviews with staff and family members highlighted the inadequate staffing levels and their impact on resident care. Staff reported being unable to provide the necessary supervision for Resident #102, who was impulsive and prone to falls. Family members expressed concerns about the resident's safety and the increased frequency of falls compared to when the resident was at home. The Director of Nursing acknowledged the staffing shortages and the challenges in providing the required level of supervision for Resident #102. Resident #100 also experienced inadequate care due to staffing shortages. The resident, who required assistance with activities of daily living, was not able to get out of bed and into a wheelchair on days when staffing was short. The care plan indicated the need for daily grooming, but the resident was observed with significant facial hair and was not out of bed during the survey period. Staff interviews confirmed that showers and other care tasks were delayed or not completed due to insufficient staffing, leading to longer wait times for assistance and unmet care needs.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to preserve resident dignity during care for two residents. Resident #100, who had diagnoses including cerebral infarction, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, was observed with significant facial hair despite a care plan intervention stating she preferred to be shaved daily. Observations and interviews revealed that shaving was only performed on shower days, which was confirmed by the Director of Nursing and Certified Nurse Assistants. A family member expressed concern that Resident #100 would be embarrassed by her unshaven appearance, and often had to shave her himself. Resident #103, diagnosed with cerebral palsy and muscle contractures, was transferred via a mechanical lift with her room door open, allowing anyone in the hallway to observe the process. The Certified Nurse Assistant involved acknowledged that the door and curtain should have been closed to maintain privacy. The facility's policy on promoting and maintaining resident dignity, which includes grooming residents according to their preferences and maintaining privacy, was not adhered to in these instances.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party regarding a change in condition, which resulted in a delay in transferring the resident to the emergency room for evaluation and treatment. The resident, who had a history of cerebral infarction, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, was observed by a registered nurse to have a decreased level of consciousness and was not responding to stimuli as usual. Despite these observations, the resident's family was not informed of the change in condition, which is a requirement according to the facility's policy. Multiple staff members, including registered nurses, the assistant director of nursing, and the medical doctor, confirmed that they did not contact the family when the change in condition was noted. The family only became aware of the situation when they visited the resident and noticed the change themselves. The facility's policy mandates that the family should be notified of significant changes in a resident's condition, but this was not adhered to, leading to a delay in the resident receiving necessary medical attention.
Lack of Physician Orders for Wound Care and Compression Stockings
Penalty
Summary
The facility failed to ensure that wound care and compression stocking physician orders were in place for a resident, leading to care being provided without the direction of a physician. The resident, who was admitted with diagnoses including varicose veins, chronic kidney disease, right bundle branch block, and Waldenstrom macroglobulinemia, did not have any skin issues noted in a recent assessment. However, a care plan indicated a risk for impaired skin integrity, and interventions included administering medications as ordered and notifying a physician of any new skin impairments. Despite this, there were no physician orders for wound care or compression stockings for the resident. A nurse's note documented an incident where the resident cut their hand on a gait belt, but there was no record of physician notification. Observations revealed that a CNA applied compression stockings, and the DON performed a dressing change on the resident's hand without physician orders. Interviews with the DON and an RN confirmed the absence of necessary physician orders, with the DON noting that the resident's spouse requested the compression stockings, although there was no swelling to justify their use.
Resident Chokes Due to Incorrect Meal Tray and Lack of Supervision
Penalty
Summary
The facility failed to ensure that a resident received the correct food tray and necessary assistance during mealtime, leading to a tragic incident. A resident with a history of dysphagia, paralysis, and cognitive communication deficits was mistakenly given a regular diet tray instead of their prescribed pureed diet with honey-thick liquids. This error occurred because a new Certified Nursing Assistant (CNA) in orientation, who was unfamiliar with the residents, delivered the wrong tray without proper supervision or verification. The resident, who required one-person assistance during meals due to their condition, began choking on a piece of cauliflower from the incorrect tray. Despite immediate attempts by the Registered Nurse (RN) to perform the Heimlich maneuver and subsequent CPR, the resident was unable to be resuscitated and later died at the hospital. The incident was exacerbated by the fact that the facility was short-staffed, with only two nurses on shift, and the CNA responsible for the error did not have access to the charting system to verify the resident's diet. Interviews with staff and family members revealed that the wrong trays were frequently given to residents, indicating a systemic issue with meal service procedures. The CNA involved in the incident admitted to not verifying the meal tray due to being directed to assist another resident, highlighting a lack of proper training and oversight during the orientation process. The facility's failure to ensure accurate meal service and adequate supervision directly contributed to the resident's choking and subsequent death.
Removal Plan
- The facility identified that a resident was given a regular diet instead of his ordered puree honey thick liquid diet. The resident began choking and ultimately requiring CPR. The facility identified that the CENA in orientation did not have her preceptor with her and did not know how to identify residents.
- The Director of Nursing and/or designee began education of facility staff on providing accurate diet, not providing care without preceptor/Nurse in attendance until relieved from Orientation, and that preceptors will not leave or allow new employees to provide care until they are deemed competent to provide care without preceptor. Staff were also educated on utilizing the kiosk when needing to identify residents.
- NHA and DON were educated on orientation process and preceptor expectations as well as the policy for orientation.
- The facility implemented resident diet info binders to include diet terminology conversion, pictures of diets and allowable foods for texture, resident pictures who have altered diets.
- The facility implemented re-education upon identification that staff were unable to verbalize use of resident diet info binders.
- The facility has 15 Licensed Nurses and 27 C.E.N.A.'s. The facility had educated 6 of the 15 Licensed Nurses and 14 of the 27 C.E.N.A/s.
- Any staff not educated at the time would not be permitted to work a shift until education had been completed.
- The facility Medical Director was notified.
- The Director of Nursing and/or designee completed an audit on all residents with an altered diets to ensure orders are entered correctly and match the binders. This audit for accuracy was completed and no concerns noted.
- The QAPI committee has reviewed the Orientation policy, therapeutic diet orders and ADLs and has deemed them appropriate.
- The facility had an Ad hoc QAPI meeting including the Medical Director (via phone) and deemed this removal plan appropriate.
- The Administrator and Director of Nursing are responsible for continued compliance.
Failure to Report Resident Choking Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who choked and subsequently died after receiving the wrong meal tray. The resident, who had a history of paralysis, aphasia, cognitive communication deficit, dysphagia, and other conditions, was on a National Dysphagia Diet Level 1 diet with pureed texture and honey-thick liquids. Despite these dietary restrictions, a new Certified Nursing Assistant (CENA) in orientation mistakenly served the resident a regular meal tray, which led to the choking incident. During the incident, the resident was sitting in the dining room when they began choking after being served the incorrect meal. A Registered Nurse (RN) attempted the Heimlich maneuver multiple times without success, and the resident turned blue and showed no air exchange. The resident was then placed on the floor, and CPR was initiated. Emergency Medical Services (EMS) arrived, continued resuscitation efforts, and transported the resident to a local hospital, but the resident did not regain a spontaneous pulse. The incident was not reported to the State Agency as required by facility policy. The facility's administrator stated that they were advised by corporate not to report the incident, believing it was the hospital's responsibility to do so. As a result, the incident went unreported, which is a violation of the facility's policy and procedure for reporting suspected neglect or abuse to the appropriate authorities.
Sanitary Conditions and Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, a container of breakfast sausage was found in the walk-in cooler, tightly covered with saran wrap and warm to the touch, with a temperature of 109°F. It was revealed that the sausage links had been pulled from the breakfast line about an hour prior and placed in the cooler. The cooling temperature log showed previous instances where cooling for sausage was logged above 70°F after two hours, indicating improper cooling practices. Further observations during the tour revealed additional sanitary issues. A box of raw hamburgers was found open and exposed in the walk-in freezer, violating food protection standards. Several saucepans were heavily encrusted with black carbon accumulation, and the dish machine area had a loose drain leaking water on the floor. The dish machine's wash temperature was consistently logged below the required minimum of 160°F, as per the machine's data plate, indicating non-compliance with mechanical warewashing equipment standards. Additional deficiencies were noted in the storage and labeling of food items. Open containers of thickened juices and nutritional shakes were found without proper date labeling, exceeding the recommended time for safe consumption. These observations highlight a lack of adherence to food safety protocols, including proper cooling, storage, and equipment maintenance, which are essential to prevent cross-contamination and ensure the safety of food served to residents.
Resident Privacy and Dignity Concerns
Penalty
Summary
The facility failed to ensure resident dignity and rights to privacy were honored, as reported by eight of nine residents during a confidential Resident Council meeting. Residents expressed feelings of frustration and disrespect due to ongoing privacy issues. One resident reported that a sign on her door, intended to ensure staff knocked before entering, was removed and not replaced. Another resident mentioned that staff entered his room without knocking. Additionally, five residents noted that during the third shift, staff were often distracted by their phones or tablets, wearing earbuds, and sometimes engaged in phone conversations while in resident rooms. The Resident Council minutes from a previous meeting indicated that residents had previously raised concerns about staff entering rooms without introducing themselves or greeting the residents. During interviews, the Activities Director was unaware of recent privacy concerns, believing previous issues had been resolved. The Nursing Home Administrator also believed there had been improvements in privacy concerns based on completed audits.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve concerns and grievances reported during Resident Council Meetings, as evidenced by interviews and record reviews. Seven out of nine residents expressed that their concerns were not being resolved, despite being brought up in meetings and to various staff members. Specific issues included long wait times for showers, cold food, and extended call light response times. Residents reported having to repeatedly ask for assistance, with some waiting weeks for showers or experiencing cold meals frequently. The Resident Council minutes from January to June 2024 documented ongoing complaints about these issues, indicating a lack of resolution over several months. The Activities Director (AD) acknowledged awareness of these concerns and stated that they were communicated to the appropriate department heads. However, the AD did not fill out grievances from Resident Council meetings unless they pertained to missing laundry items. The facility's policy requires the use of a Resident Council Minutes and Quality Assistance Form to track issues and their resolution, with the Administrator responsible for ensuring all group concerns are investigated and responses provided. Despite this policy, the facility did not effectively address or resolve the residents' grievances, leading to unmet needs and dissatisfaction among the residents.
Facility Fails to Maintain Adequate Linen Supplies and Sanitary Conditions
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment by not maintaining adequate supplies of bath linens and incontinence products, leading to unsanitary conditions and frustration among residents. Resident #13, who has multiple sclerosis and requires assistance with personal care, reported that the facility frequently ran out of washcloths and the preferred type of incontinence briefs. Staff interviews confirmed these shortages, with reports of staff resorting to cutting towels to make washcloths and taping smaller briefs together to accommodate residents' needs. Observations revealed a lack of washcloths in the clean utility room, and staff confirmed that the facility often ran out of necessary supplies. Resident #18, who is cognitively intact and has heart failure, also reported frequent shortages of washcloths and other supplies, which had been communicated to management without resolution. During a confidential resident council meeting, several residents expressed concerns about the lack of towels, washcloths, and linens, indicating that these issues had been ongoing and previously reported to staff. The facility's decision to stop using disposable wipes and increase the use of washcloths further exacerbated the shortage, as the ordered washcloths had not yet arrived. Additionally, the facility failed to maintain sanitary conditions in common areas, as evidenced by the thick buildup of dust and debris on artificial trees in the resident common area. Despite housekeeping efforts, the dust remained, contributing to an unsanitary environment. The laundry area also showed signs of neglect, with trash and debris accumulating under equipment, and a lack of clean washcloths in stock. Interviews with laundry staff and management revealed that the facility lacked a par count system to ensure adequate linen supplies, further contributing to the deficiency.
Failure to Provide Routine Showers
Penalty
Summary
The facility failed to provide routine showers for several residents, leading to feelings of frustration, disappointment, and embarrassment among the affected individuals. Resident #11, who has multiple sclerosis and is dependent on a wheelchair, reported not receiving showers twice a week as scheduled, missing 7 out of 25 opportunities. This resident expressed frustration about the lack of support in meeting her hygiene needs. Similarly, Resident #13, also with multiple sclerosis and requiring full assistance for showers, missed 10 out of 24 scheduled opportunities, leading to feelings of self-consciousness and a negative impact on her outlook and energy levels. Resident #22, with moderate cognitive impairment and a history of stroke, was observed with greasy hair and a strong smell of urine, indicating a lack of personal hygiene care. This resident missed 11 out of 24 scheduled shower opportunities and expressed concern about her appearance and odor. Resident #35, who is cognitively intact, reported missing showers frequently, including a period of 11 days without one. Despite raising concerns with facility management, the issue persisted, and the facility was unable to provide shower records for this resident. The deficiency was further highlighted during a confidential resident council meeting, where seven out of nine residents reported not receiving showers as scheduled. The facility's Director of Nursing acknowledged the issue, attributing it to staffing shortages, and the Nursing Home Administrator believed there had been improvements based on audits, although the problem remained unresolved. The facility's failure to provide necessary services to maintain personal hygiene was a clear violation of their policy and resulted in significant dissatisfaction among residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in long call light wait times, missed showers, and insufficient supervision. Several residents, including those with multiple sclerosis, anxiety disorders, and cognitive impairments, reported delays in receiving assistance for daily activities such as getting out of bed, dressing, and showering. These delays were attributed to the lack of sufficient staff, with reports indicating that often only one CNA was available per unit, making it difficult to provide necessary care, especially for residents requiring two-person assistance. Interviews with staff, including CNAs and RNs, confirmed the staffing shortages and the challenges they faced in providing timely care. Staff reported that open shifts frequently went unfilled, and management did not use contractual staff to cover these gaps. The facility's staffing levels were based on resident census rather than acuity, and there was no provision for additional staff based on the specific needs of residents. This led to situations where residents had to wait extended periods for assistance, affecting their personal hygiene and overall quality of life. The deficiency was further highlighted during a confidential resident council meeting, where residents expressed their dissatisfaction with the long wait times for assistance and the impact on their daily routines. The facility's nursing home administrator acknowledged the staffing issues but attributed them to the need for better teamwork among existing staff rather than an increase in staffing levels. Despite concerns raised by both residents and staff, the facility had not implemented measures to address the staffing shortages effectively.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable temperature to residents, as observed during a survey. During a lunch service tour, it was noted that hot food on the steam table should be around 165F to remain hot for residents. However, a test tray of the regular meal showed that the pasta/meat was at 122F and the peas were at 121F, indicating that the food was not served at the appropriate temperature. Similarly, during a breakfast service, the scrambled eggs were at 124F, sausage links at 103F, and oatmeal at 125F, all below the expected temperature. Residents consistently reported that their food and drinks, such as coffee, were cold, whether served in their rooms or the main dining room. Resident #15, who is cognitively intact, and Resident #27, who is moderately impaired, both reported that their food was almost always cold. The issue of cold food had been raised multiple times in Resident Council meetings, with records showing that residents had been experiencing this problem for several months. Despite these concerns being communicated to the appropriate department head, the problem persisted. The Regional Dietitian acknowledged that trays might sit if residents are not present when delivered, suggesting that another tray should be requested or delivery should be timed better.
Failure to Provide Nourishing Nighttime Snacks
Penalty
Summary
The facility failed to consistently provide a nourishing nighttime snack to eight of nine residents who attended a confidential Resident Council meeting. These residents reported not receiving snacks at bedtime, and when they did request them, they were often given only one choice. One resident noted the lack of healthy options, mentioning that the snacks were salty and not diabetic-friendly. Another resident expressed suspicion that staff might be consuming the snacks meant for residents. The review of the facility's mealtime schedule showed a potential gap of 13-14 hours between dinner and breakfast, which could lead to decreased oral intake and potential weight loss. The facility's policy on offering bedtime snacks requires nursing staff to offer snacks in accordance with residents' needs, preferences, and requests, and to document the intake in the medical record. However, during interviews, it was revealed that while the dietary staff stocked the nourishment room with a variety of snacks, the nursing staff was responsible for distributing them. Despite this, residents reported issues with the availability and variety of snacks, and there were allegations of staff consuming the snacks. The Resident Council minutes also documented a resident's observation of CNAs taking snacks for themselves, which was not addressed by the facility.
Inaccurate Advanced Directive Information
Penalty
Summary
The facility failed to ensure accurate advanced directive information was in place for a resident, resulting in the potential for the resident's preferences for medical care to not be followed. The resident was admitted with a diagnosis of adult failure to thrive and had an advance directive signed by their guardian indicating a preference for no resuscitation in the event of cardiac or respiratory arrest. However, the electronic health record (EHR) listed the resident as full resuscitation, which was inconsistent with the advance directive. Interviews with facility staff revealed that they relied on the EHR to determine a resident's code status in emergencies. A Certified Nursing Assistant and a Registered Nurse both confirmed this practice. The daily report sheet for the resident did not indicate the code status, and the Social Worker acknowledged that the facility had missed the error in the EHR. The facility's policy stated that advance directives should be reviewed during quarterly care planning sessions or with significant changes in condition, but the Social Worker could not confirm the date of the resident's most recent care conference.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident, resulting in the potential for unmet mental health and psychiatric care needs. The resident was admitted with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and suicidal ideations. The resident's Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening indicated the presence of mental illness, treatment for mental illness, recent use of antipsychotic or antidepressant medications, and evidence of mental illness or dementia. Despite these indicators, the resident's Electronic Health Record did not contain a Level II PASARR screening. The Regional Social Worker (RSW) responsible for completing PASARR screenings reported that she had completed the Level II screening and noted the resident as dementia exempt. However, the screening was still awaiting review and signature from the facility's medical doctor. The RSW stated she was not responsible for ensuring the completion of the PASARR process and was unaware that the screening was pending review. The Medical Doctor (MD) reported not reviewing the Level II screening because she was not informed of her responsibility to review PASARR screenings and did not have the necessary login credentials to access the forms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, resulting in an incomplete reflection of their status and potential unmet care needs. Resident #12, a cognitively intact female with stiffness in her wrists and hands, reported that she had splints for her hands to wear at night but often forgot to do so without staff reminders. Therapy staff confirmed that Resident #12 required assistance to apply the splints and had a history of non-compliance with therapy recommendations. Despite these needs, the care plan for Resident #12 lacked any focus, goals, or interventions related to her non-compliance with therapy recommendations or the use of hand splints. Resident #27, who was cognitively impaired and had diagnoses including End Stage Renal Disease, Type 2 diabetes, and depression, attended dialysis three times a week. However, the facility did not have a nursing care plan in place for his dialysis status upon admission. Although the Registered Dietitian had put a nutrition care plan related to dialysis, the nursing dialysis care plan was not completed until later, under impaired genitourinary status. The facility's policy required the care plan to reflect coordination between the facility and the dialysis provider, including specific interventions, but this was not initially done. The lack of comprehensive care plans for both residents indicates a failure to adequately address their specific medical needs and conditions. This deficiency was identified through interviews and record reviews, highlighting the facility's oversight in ensuring that care plans were updated and reflective of the residents' current health status and treatment requirements.
Delay in Lab Processing Leads to Prolonged Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident who experienced dysuria for approximately two weeks. The resident, who was cognitively intact, reported pain with urination and increased frequency, prompting an order for a urinalysis with reflex to culture and sensitivity. However, the urine specimen collected on the initial date was sent to the wrong lab due to a recent switch in lab providers, and the nurses were unclear on the new process. This mishandling resulted in a significant delay in obtaining the necessary lab results and subsequent treatment. Interviews revealed that the nursing staff did not monitor the pending lab results, and the resident's continued reports of pain were not communicated to the provider in a timely manner. The Director of Nursing acknowledged the lack of training on the new lab process and the absence of documented assessments of the resident's symptoms in the electronic health record. The delay in obtaining a second urine sample and the lack of provider assessment contributed to the resident's prolonged discomfort and delayed treatment for vulvovaginitis.
Failure to Reassess Resident's Use of Therapy-Recommended Device
Penalty
Summary
The facility failed to reassess a resident's preference for using a therapy-recommended positioning device, specifically hand splints, which resulted in the potential for decreased range of motion and related complications. The resident, who was cognitively intact, had a history of stiffness in her wrists and hands, and an amputation of a right toe. She reported needing assistance to apply the splints and that staff did not remind her to wear them, leading to her belief that her hand condition was worsening. Observations and interviews revealed that the resident had a schedule to wear the splints on alternating hands each night, but staff did not consistently assist her in following this schedule. Therapy staff had posted a sign in the resident's room to alert staff of the need to apply the splints, but during an observation, no such sign was found. The therapy staff also reported that the resident had a known history of non-compliance with therapy recommendations, but there was no physician's order in place for the splints, nor was there documentation of the resident's refusal to wear them. The Senior Director of Nursing indicated that a physician's order was necessary for therapy recommendations and that these should be included in the care plan. However, a review of the resident's care plan showed no focus, goals, or interventions related to the resident's non-compliance with therapy recommendations or the use of hand splints. This lack of documentation and follow-through on therapy recommendations contributed to the deficiency identified by the surveyors.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate supra-pubic catheter care for a resident, leading to the potential for urinary tract infection and complications related to catheter tubing occlusion. The resident, who was admitted with diagnoses including tubulo-interstitial nephritis, obstructive uropathy, and unspecified hydronephrosis, had an indwelling urinary catheter as per their care plan. The care plan included interventions such as observing for signs of urinary tract infection and changing the catheter as clinically indicated. However, the resident's catheter had not been changed since May, despite observations of dark, orange-tinged urine with cloudy sediment and a strong smell of urine in July. During interviews, a registered nurse acknowledged that catheters should be changed when sediment is present but was unaware of the last catheter change for the resident or the facility's process for tracking catheter replacement frequency. The medical director also noted that the catheter had been in place too long, increasing the risk of infection. The facility's catheter care policy aimed to reduce infections, but the lack of adherence to this policy resulted in the deficiency.
Inadequate Care for Resident with Enteral Nutrition
Penalty
Summary
The facility failed to provide adequate care for a resident receiving enteral nutrition, specifically for Resident #21, who was admitted with diagnoses including adult failure to thrive and dysphagia following a stroke. The resident had orders for continuous tube feeding with Jevity at 50 ml/hr and required the head of the bed to be elevated between 30-45 degrees. However, during observations on two separate occasions, it was noted that the resident's bed was not elevated as required, and the Jevity bottle lacked essential labeling information such as the open date, start date and time, and the initials of the nursing staff member who initiated the tube feeding. Interviews with the RN and the Director of Nursing (DON) confirmed these deficiencies. The RN acknowledged the incorrect bed positioning and the missing labeling on the Jevity bottle. The DON stated that nurses were expected to ensure proper bed elevation during tube feeding and to label the feeding formula with the date and time it was started. The facility's Feeding Tube policy, last revised in June 2022, mandates that feeding tubes be maintained according to current clinical standards and physician orders, which were not adhered to in this case.
Failure to Obtain Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to obtain physician orders for the use of oxygen for a resident, resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection. The resident was admitted with a diagnosis of weakness, but there were no orders for oxygen administration in their records. Observations revealed the resident receiving oxygen via nasal cannula at varying flow rates, without a corresponding care plan focus area related to oxygen use. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed the absence of a physician's order for the oxygen. The medical doctor was unaware of the resident's oxygen use and had not approved any orders for it.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of physician-ordered laboratory services for a resident, resulting in delayed treatment and increased discomfort. The resident had a urinalysis ordered on 7/12/24 due to experiencing pain with urination, but the facility did not receive the results. It was discovered on 7/19/24 that the results were never obtained, prompting a request for another urine sample. Interviews revealed that the urine sample was sent to the wrong lab due to a recent switch in lab providers, and there was confusion among the nursing staff regarding the new lab ordering process. The Director of Nursing confirmed that the facility had not yet provided education and training to all nursing staff responsible for lab orders. The facility's policy required tracking and monitoring of lab tests, but the Director of Nursing could not confirm if the resident's lab order was followed up on. The Medical Doctor and Registered Nurse both acknowledged the delay in treatment and care due to the miscommunication and lack of tracking of the lab order, which was not completed as required by the facility's guidelines.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices, leading to unsanitary conditions and the potential for the spread of infection among residents. Resident #103, who required enhanced barrier precautions (EBP) due to a urinary catheter, was found in a room with a strong smell of dried urine and visibly soiled surfaces. Certified Nurse Aide (CNA) U performed catheter care without donning the required personal protective equipment (PPE) and admitted to not receiving formal training on EBP guidelines. Additionally, the transmission-based precautions (TBP) cart in Resident #103's room was not noticed by the CNA until pointed out by the surveyor. Resident #104, diagnosed with psoriatic arthritis, was observed with blood-stained linens and visibly soiled skin. The resident's care plan required daily linen changes due to her skin condition, but this was not adhered to. Registered Nurse (RN) P confirmed that Resident #104's linens should be changed daily and admitted to not being informed or educated on EBP for residents with open skin areas. The resident's bedside table was also found to be visibly soiled, and the resident reported that staff did not change her bedding frequently. Resident #107, who had a pressure ulcer and required EBP, was assisted by CNA F without the use of proper PPE. The CNA admitted to knowing the requirements but failed to follow them. Additionally, shared equipment such as mechanical lifts and electric wheelchairs were found to be heavily soiled and not sanitized between uses. Staff reported that cleansing wipes were not always available, leading to inconsistent cleaning practices. The facility's infection prevention and control program policy was not effectively implemented, resulting in unsanitary conditions and the potential for cross-contamination and disease transmission.
Failure to Respect Resident Privacy
Penalty
Summary
The facility failed to respect residents' private space, resulting in feelings of embarrassment and potential negative psychosocial outcomes for three residents. Resident #103, who was mildly cognitively impaired, experienced an incident where a staff member entered the room without proper knocking while catheter care was being performed, exposing the resident's private parts. Resident #103 reported that staff rarely knock and often just walk in, and also mentioned that call lights are not answered promptly. The staff member involved admitted to not following the procedure for resident privacy. Resident #107, who was cognitively intact, was being assisted with toileting when another staff member knocked once and entered the room without waiting for a response, leaving the bathroom door open and exposing the resident. The staff member assisting Resident #107 acknowledged that they should have communicated to prevent the interruption. Resident #111, also cognitively intact, reported that staff rarely knock and often enter without respecting privacy. The facility's policy on resident rights did not include specific information on resident privacy rights.
Failure to Accommodate Resident Choices and Preferences
Penalty
Summary
The facility failed to accommodate a resident's right to make choices consistent with their plan of care for three residents. Resident #107, who was cognitively intact and dependent on assistance for toileting hygiene, reported sitting in a heavily soiled brief since the previous night. Despite asking multiple staff members for help, she did not receive assistance until a surveyor intervened. The CNA who eventually assisted her failed to ensure proper hygiene and did not check the resident's wound dressing as requested by a nurse. Resident #104, who was mildly cognitively impaired and had chronic respiratory failure, reported not receiving any care on the day of the observation. She expressed a preference for daily bed baths, which were not being provided. Her linens, which were stained with blood due to her psoriasis, were not changed regularly, despite the nurse acknowledging that they should be. Resident #111, who was cognitively intact and had a history of stroke, reported that night staff were supposed to check on him and empty his urinals but often failed to do so. This led to his urinals being too full to use by morning, causing potential spills. The facility's Quality Assistance Forms and Resident Council Minutes revealed ongoing issues with staff responsiveness, cleanliness, and food quality, indicating a broader pattern of neglecting resident preferences and needs.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's narcotic medications, specifically Oxycodone IR 15 mg, for one resident. The incident was identified when a Licensed Practical Nurse (LPN) noticed that the narcotic count sheet had been altered, showing a change from 19 to 14 tablets with two nurses' signatures indicating that four tablets were wasted. The LPN admitted to removing the pills from a torn blister pack and placing them in a medication cup to destroy later but inadvertently threw them away. The facility could not substantiate that the LPN took the medications, but her employment was terminated for failing to follow the narcotic destruction policy and falsifying a signature. The facility requested replacement pills from the pharmacy and billed them to the facility. Despite the incident, residents, including the affected resident, reported receiving their medications without issues, and a review of all narcotics in the center revealed accurate counts and no other discrepancies. The affected resident, who was cognitively intact and diagnosed with multiple sclerosis, had a physician's order for Oxycodone HCl 15 mg to be taken four times a day for chronic pain. During the investigation, it was found that the narcotic count sheet for the resident's Oxycodone had been altered with white-out, which is against the protocol for controlled substances. The Director of Clinical Services (DCS) and other staff conducted a thorough audit of all medication carts and narcotic medications, finding no other concerns. The facility also implemented training and audits with all nurses to ensure compliance with protocols for handling controlled substances. Interviews with various staff members, including the DCS, Registered Nurse (RN), and other LPNs, confirmed that multiple training sessions and audits were conducted to reinforce the proper procedures for handling and documenting controlled substances. The facility also ensured that two nurses were always present when counting and destroying controlled substances, and that no white-out was used on any documentation. The facility reported the incident to the State Agency and conducted an internal investigation, which included ongoing audits and education to prevent future occurrences.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to provide palatable food for three residents, resulting in dissatisfaction with the quality, portion size, taste, and temperature of their meals. Observations revealed that many meal trays had 50%-75% of the food uneaten. Certified Nurse Aides reported frequent complaints from residents about the food being repetitive, cold, and unappetizing. Residents also reported issues such as food being served still frozen, lack of variety in the alternative menu, and insufficient water service. One resident mentioned that the facility had run out of milk for a day, and another reported receiving raw chicken. The Regional Registered Dietician acknowledged the issues, attributing them to staff turnover and the kitchen's focus on menus suitable for Assisted Living residents rather than those in Long Term Care. Resident #102, who is cognitively intact, reported that the facility often lacks menu items and that her water is not refreshed as required. She also mentioned receiving food that was still frozen inside. Resident #104, who is mildly cognitively impaired, echoed similar complaints about the food being cold, bland, and repetitive. Resident #111, also cognitively intact, described the food as disgusting, citing instances of raw chicken and small portion sizes. Observations and interviews with staff confirmed these issues, with one CNA noting that the alternative menu options are rarely available to Long Term Care residents. The Regional Registered Dietician confirmed that a significant amount of food is returned uneaten, highlighting the severity of the problem.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not properly cleaning resident rooms, common areas, and commonly touched items. This resulted in strong odors and an increased potential for infection. Resident Council Minutes from January to March revealed multiple complaints about dirty dining tables, uncleaned floors under beds, and overflowing trash cans. Observations confirmed these issues, with multiple cloth chairs in the TV area visibly soiled and emitting a strong smell of dried urine. Resident #102, who was cognitively intact, reported that her room was not cleaned daily, especially under her bed, and that stale urine odors were present due to improper cleaning of urine spills. Resident #104, who was mildly cognitively impaired, had a bedroom floor that was visibly soiled with food crumbs, dust, debris, and random wrappers. The floor was sticky, and a heavy accumulation of dust and debris was found under the bed. Housekeeping staff admitted that due to being short-staffed, sweeping and mopping were not always completed for every resident. The facility's policy required routine cleaning of environmental surfaces and non-critical resident care items, but this was not adhered to.
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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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