Medilodge Of Howell
Inspection history, citations, penalties and survey trends for this long-term care facility in Howell, Michigan.
- Location
- 1333 W Grand River, Howell, Michigan 48843
- CMS Provider Number
- 235331
- Inspections on file
- 38
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Medilodge Of Howell during CMS and state inspections, most recent first.
A resident with common variable immunodeficiencies and Crohn’s disease had a standing weekly order for Hizentra, an immune globulin therapy, but the MAR over several months showed repeated entries of the drug as not available or not given, with only sporadic administrations. The resident, who was cognitively intact, reported not receiving the medication for months despite expecting weekly doses. The DON stated the drug was supplied by a specialty pharmacy, and a pharmacy employee confirmed that the last monthly shipment was delivered in early September and that no further contact from the facility occurred afterward. This pattern shows the facility did not ensure the physician-ordered Hizentra was consistently obtained and administered in accordance with its own medication administration policy.
Two residents experienced medication administration failures when staff did not follow professional standards for reconciling and giving ordered drugs. A resident with immune deficiency and Crohn’s disease had a weekly Hizentra order, but the MAR showed repeated "not available" entries and sporadic documented administrations despite the specialty pharmacy confirming no shipments after an earlier month and the facility keeping no delivery records, leaving the accuracy of MAR entries in question. Another resident with cardiac and kidney disease returning from a hospital stay for severe sepsis and cellulitis had an order for Amoxicillin TID, but an LPN entered the order with an incorrect future start date, and subsequent nursing reconciliations did not detect the error, resulting in several days without the antibiotic until an NP and RN identified and corrected the omission.
A resident with severe wounds and a complex pain regimen did not receive ordered Oxycodone for pain management despite repeated requests and nursing assurances. Documentation confirmed that the medication was not administered as ordered, resulting in a significant delay before the resident received the first dose.
A nurse mistakenly administered a resident the full dose of his roommate's medications, which included multiple anticonvulsants, a benzodiazepine, an antipsychotic, and a diabetic medication. The resident, who had complex cardiac and metabolic conditions, became increasingly lethargic and unresponsive over several hours, prompting transfer to the hospital. The error was recognized immediately, but there were delays in provider response and follow-up as the resident's condition worsened.
A deficiency was identified when the facility did not provide enough nursing staff with the required competencies to meet the medical and supervision needs of multiple residents, as determined by their assessments and care plans.
The facility did not report allegations of abuse and mistreatment involving two residents to the State Agency as required. One resident, with a documented history of behavioral and substance abuse issues, was alleged to have inappropriately touched another resident and exhibited ongoing aggressive behavior. Staff were aware of the incidents but failed to follow mandated reporting procedures.
A resident with symptoms of a UTI experienced a delay in assessment, lab processing, and initiation of antibiotics, despite ongoing decline and documented signs of infection. Another resident with quadriplegia and a stage 4 pressure ulcer faced a prolonged delay in obtaining a medically necessary power tilt recline wheelchair due to the facility's failure to submit required documentation, resulting in distress and frustration for the resident.
A resident exhibiting symptoms of a UTI had a urine specimen collected, but the lab did not pick up the specimen for processing until two days later, resulting in a delay in diagnosis and treatment. The DON confirmed that specimens are supposed to be picked up daily, and the facility's policy lacked clear timeframes for lab collection and transport.
Two residents with cognitive impairment and alcohol dependence were found intoxicated together, resulting in an abuse allegation that was not promptly reported to the administrator as required by facility policy. During the same shift, the facility was understaffed, leading to delayed medication administration and inadequate supervision for multiple residents, including those with behavioral issues.
A resident admitted with severe injuries requiring enteral feeding experienced a 15-hour delay in receiving nutrition due to a lack of a feeding pump. Despite the availability of supplies, the facility was replacing pumps, causing the delay. The nursing staff failed to document the feeding administration timely, and the facility's policy on feeding tubes was not followed.
A facility failed to prevent falls and ensure timely investigation for two residents, leading to one sustaining a femoral neck fracture. A resident with severe cognitive impairment was found on the floor by a CNA, who did not immediately assist or notify the nurse. The resident was improperly assisted back to bed without injury assessment, and later complained of pain. Another resident with a history of falls experienced multiple falls due to inadequate supervision and failure to implement recommended interventions.
The facility's call system failed to effectively alert caregivers, relying solely on a hallway monitor that staff had to check periodically. Interviews with staff and residents revealed that there were no audible or visual alerts, and pagers were not in use. Residents reported long wait times for assistance, and the facility's leadership acknowledged the issue but had not implemented a solution.
The facility failed to adhere to professional standards for medication administration and disposal. A resident had a prescription left unsecured in their room without an order, and another resident was left with medications to self-administer without supervision or an order. Additionally, a nurse improperly disposed of liquid medication by pouring it down the drain, against facility policy.
A resident with mixed incontinence and other conditions did not receive scheduled showers, as only four were documented over a 30-day period. The resident reported staff postponing her requests, and observations confirmed inadequate hygiene care, including a soiled brief and skin issues. The DON confirmed the lack of documentation for the required showers.
The facility failed to follow infection control protocols, as staff were observed exiting a resident's room with PPE still on, contrary to CDC guidelines. Additionally, a resident's catheter bag was found touching the floor, and there was a delay in implementing Enhanced Barrier Precautions due to an outbreak, despite physician orders being in place.
The facility failed to provide necessary social services for two residents. One resident with severe cognitive impairment lacked a legal decision maker, and no initial social service assessment was completed. Another resident with a history of suicidal behavior was not properly followed up after a hospital visit for suicidal ideations, with no documentation of evaluation or safety checks. The facility did not adhere to its social services responsibilities, failing to perform assessments and update care plans.
The facility failed to accurately reconcile controlled medications for two residents. A nurse forgot to administer a Hydrocodone/Acetaminophen tablet to a resident after being distracted, leading to a discrepancy in the narcotic binder. Another nurse administered a Tramadol tablet but did not update the binder, resulting in a mismatch between the recorded and actual tablet count. The DON was informed of these issues.
A facility failed to complete physician-ordered lab diagnostics for a resident with respiratory issues. Despite a Nurse Practitioner ordering a STAT CO2 level and CMP due to shortness of breath, the tests were not conducted, and no results were available. The DON confirmed the oversight, and the Administrator acknowledged an issue with lab diagnostics.
A resident with hand contractures and other conditions did not receive necessary rehabilitative services, including periodic screenings and maintenance programs, leading to a lack of intervention for their condition. Observations showed the resident's hands in a clenched position without the use of prescribed palm protectors. Staff interviews confirmed the absence of a maintenance program since 2023, and the facility lacked a process for routine screening or assessment of range of motion for residents with contractures.
A resident with multiple medical diagnoses, including heart failure and dementia, consented to receive a pneumonia vaccine. Despite this consent, the vaccine was not administered, as confirmed by the Infection Preventionist and Corporate Clinical Services. The Electronic Medical Record incorrectly documented the vaccine as refused.
The facility failed to offer and administer the COVID-19 vaccine in a timely manner to two residents, one with moderate cognitive impairment and multiple medical conditions, and another with severe cognitive impairment. Delays were due to oversight and insurance authorization issues, leading to a deficiency in the immunization process.
A resident with multiple health issues reported missing personal items and other concerns to the facility, which failed to document and promptly resolve these grievances. The facility's grievance process was found lacking, with no documentation or follow-up on issues related to medication, care, and appointments. Interviews revealed inconsistencies in the grievance process, and the facility's policy lacked specifics on resolving grievances.
A resident with diabetes and foot issues did not receive timely podiatry care despite a physician's order. The resident experienced foot pain and swelling, and had ingrown toenails, but the facility failed to ensure a podiatry consult was completed. Staff interviews revealed a lack of awareness and issues with the electronic medical record system, leading to a delay of over 40 days in obtaining necessary care.
The facility failed to provide proper respiratory care for two residents. One resident did not receive continued oxygen therapy as per the NP's evaluation, while another was given an ill-fitting nasal cannula, making it difficult to breathe. The facility did not adhere to its policy of changing oxygen equipment weekly, and there was a lack of documentation and orders for necessary respiratory care.
A resident did not receive a scheduled dose of Haldol Decanoate due to the facility's failure to coordinate with the CMH agency. The medication was due every two weeks, but the dose on 6/28/24 was missed, leading to increased mental health symptoms. The facility did not document efforts to obtain the medication or address the issue before the resident's discharge.
A resident with a history of falls and under hospice care experienced multiple falls due to the facility's failure to provide the required two-person assistance for bed mobility. The resident rolled out of bed while a single aide was changing their brief and linens, despite the care plan indicating the need for two-person assistance. The facility staff lacked proper documentation and training on the resident's care needs, leading to repeated falls and injuries.
A resident with major depression, chronic respiratory failure, and diabetes did not receive a physician-ordered skin scraping test to rule out scabies. Despite multiple inquiries and a review of the clinical record, the facility could not provide the test results. Interviews revealed that the facility's process for ensuring laboratory orders are executed was not followed, and no explanation was given for the oversight.
Failure to Obtain and Administer Ordered Hizentra Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer a physician-ordered immune globulin medication, Hizentra, for a resident with common variable immunodeficiencies and Crohn’s disease. The resident, who was cognitively intact and had diagnoses including respiratory failure and common variable immunodeficiencies, had an order dated 2/28/25 for Hizentra 10 g/50 mL to be given subcutaneously once weekly. Although this order was discontinued on 10/22/25, a similar weekly Hizentra order was started on 10/27/25 and continued, with a later change to a Wednesday schedule beginning 3/11/26. Review of the Medication Administration Records from October 2025 through March 2026 showed multiple weeks where the medication was documented as “not available” or “not given,” with only sporadic administrations noted by nursing staff. The resident reported on 3/23/26 that they had not received Hizentra in months despite being supposed to receive it weekly and stated they had an immune-compromised disease. The DON stated the medication was supplied by a specialty pharmacy and provided a letter from the infusion pharmacy dated 3/13/26 indicating the pharmacy had been unable to reach the resident and would close the case pending a return call. In a phone interview, a pharmacy employee reported that the last monthly supply of Hizentra (four doses) was shipped to the facility on 9/2/25 for delivery on 9/3/25 and that the pharmacy had not received any calls from the facility after that shipment. The facility’s own medication administration policy required medications to be administered by licensed staff as ordered by the physician and in accordance with professional standards of practice, but the facility did not ensure ongoing availability and administration of the ordered Hizentra for this resident.
Failure to Accurately Reconcile and Administer Hizentra and Amoxicillin
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and administer prescribed medications according to professional standards for two residents. One resident with respiratory failure, common variable immunodeficiencies, and Crohn’s disease had a standing order for weekly subcutaneous Hizentra, supplied by a specialty pharmacy and stored in the medication room refrigerator. The MAR from October through March showed multiple weeks where Hizentra was documented as “not available,” interspersed with a few entries indicating administration by nursing staff. The resident reported not receiving Hizentra for months after a hospital stay in November, and the specialty pharmacy confirmed the last shipment of a one‑month supply was delivered in early September, with no subsequent orders or contacts from the facility. The Administrator acknowledged the facility did not keep records of specialty pharmacy deliveries and could not confirm that doses documented as given on the MAR were actually administered. For this same resident, nursing staff interviews revealed inconsistencies between staff recollections and pharmacy records. One nurse stated they administered Hizentra on a December date as documented on the MAR and recalled sometimes the medication was not available, while another nurse could not recall one of the documented administration dates but reported obtaining the medication from the storage room refrigerator on a later date. Despite these MAR entries, the specialty pharmacy reported no shipments after September and no calls from the facility requesting additional medication. The facility lacked a tracking system for specialty pharmacy deliveries, and there was no documentation to reconcile the discrepancy between the MAR entries, staff statements, and the pharmacy’s delivery history. A second resident, a long‑term resident with cardiac and kidney disease and moderately impaired cognition, experienced a failure in timely initiation of a prescribed antibiotic. After hospitalization for severe sepsis related to cellulitis of the left lower extremity, the infectious disease consultant and the hospital AVS directed that Amoxicillin 1 g orally three times daily be started and continued for four weeks. The resident returned to the facility, and the admitting LPN described a process in which hospital discharge orders are entered and then reviewed by a unit manager and a nursing leader. However, the MAR showed that Amoxicillin was not administered by the facility until several days after readmission. Review of the electronic orders revealed that the LPN had entered the Amoxicillin with an incorrect future start date, and the order was not corrected until identified by the NP and entered by an RN several days later. The DON and ADON confirmed that the medication was not ordered correctly and that the multiple reconciliation steps in the admission process were not performed accurately.
Failure to Timely Administer Ordered Pain Medication
Penalty
Summary
A resident with a history of trauma resulting in necrotizing fasciitis of the left upper and lower extremities was admitted for skilled nursing care and rehabilitation. The resident underwent multiple surgical procedures, including debridement, fasciotomy, and a muscle flap graft, and required a Wound VAC. The resident's pain management regimen included Oxycodone 10 mg every four hours as needed, with the last dose documented prior to admission. Upon admission, the resident requested Oxycodone, and the admitting nurse confirmed the medication was ordered and could be accessed from a backup supply until the pharmacy order was filled. Despite repeated requests by the resident and assurances from nursing staff that the medication would be provided, the resident did not receive the ordered Oxycodone as scheduled. Record review showed that the Medication Administration Record (MAR) had an active order for Oxycodone 10 mg every four hours as needed for pain, starting on the day of admission. However, there was no documentation of administration on that day, and the controlled substance record confirmed that the resident did not receive the medication as ordered. The Director of Nursing acknowledged that the Oxycodone was not provided according to the physician's order, and the resident did not receive the first dose until the following evening, resulting in a significant delay in pain management.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a nurse administered a resident the medications intended for his roommate. The incident took place during the midnight shift, when the nurse, while managing two residents in the same room, set down a cup containing the roommate's medications on the wrong resident's tray table. After assisting both residents back into bed, the nurse inadvertently gave the medications to the wrong resident. The nurse realized the error immediately after administration and attempted to notify the physician and the Director of Nursing, but did not receive an immediate response. The affected resident had multiple complex medical diagnoses, including ischemic cardiomyopathy, atrial fibrillation, congestive heart failure, diabetes, acute kidney failure, and a recent femur fracture. Following the medication error, the resident initially showed no adverse reaction, but over the next several hours became increasingly lethargic, with fluctuating vital signs and eventually became unresponsive with increased secretions. Nursing staff documented these changes and communicated with the on-call provider, who advised monitoring and did not provide new orders despite the resident's declining condition. The resident's condition continued to deteriorate, and he was ultimately transferred to the hospital for further evaluation. Documentation shows that the medications administered in error included several anticonvulsants, a benzodiazepine, an antipsychotic, and a diabetic medication, none of which were prescribed for the affected resident. The facility's records indicate that the error was recognized and reported, but there were delays and gaps in provider response and follow-up documentation regarding the resident's significant change in condition.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to ensure that sufficient nursing staff with appropriate competencies and skill sets were available to meet the medical and supervision needs of 15 residents. This deficiency was identified through interviews and record reviews, which revealed that the number and qualifications of nursing personnel were inadequate to provide necessary nursing and related services as required by resident assessments and care plans. The lack of sufficient staff included both licensed nurses and other nursing personnel, such as nurse aides, and resulted in unmet resident needs for medical care and supervision during the period reviewed.
Plan Of Correction
Element 1: Resident R907 has been reviewed for any negative outcomes related to the alleged violation by Social Services / Designee. Care plan has been reviewed and updated as needed by Social Services. Completed by 5/8/2025. Resident R901 no longer resides in the facility. Nurse staffing patterns were reviewed by the Administrator to ensure that nurse staffing was sufficient to meet all current resident needs on 5/9/2025. Element 2: Nurse staffing was reviewed for the last 14 days to ensure that staffing was sufficient to meet all current residents needs. This was completed by the Administrator / Designee on 5/9/2025. Element 3: The Nursing Services and Sufficient Staff policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The facility Administrator and Director of Nursing were re-educated on the Nursing Services and Sufficient Staff policy by the Regional Director of Operations on 5/7/2025. Staffing will be reviewed daily, Monday through Friday, in morning stand-up meetings. Any concerns will be addressed.
Failure to Report Alleged Abuse and Mistreatment to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and mistreatment to the State Agency as required, involving two residents. Specifically, an incident occurred in which one resident was alleged to have touched another resident inappropriately during the midnight shift, and there were additional concerns that the same resident was seeking out other women in the facility for sexual activity. Despite these serious allegations, the facility did not report the incidents to the State Agency in accordance with federal requirements. The medical record review and interviews confirmed that staff were aware of the events, including a commotion in the room, visible intoxication, and the presence of alcohol, but failed to follow established reporting procedures. The resident involved had a history of behavioral issues, including agitation, verbal and physical threats, and substance abuse, as documented in multiple progress notes. These notes detailed repeated incidents of aggression toward other residents and staff, including attempts to physically confront or threaten others, use of profanities, and disruptive behavior. Despite this documented pattern and the specific incident of alleged abuse, the facility did not ensure timely reporting to the appropriate authorities as required by regulation.
Plan Of Correction
Element 1: Resident R907's allegation of abuse has been reported to the State of Michigan. Completed by the Abuse Coordinator on 5/1/2025. Resident R907 has been reviewed for any negative outcomes related to the alleged violation by Social Services / Designee. Care plan has been reviewed and updated as needed by Social Services. Completed by 5/8/2025. Resident R901 no longer resides in the facility. Element 2: All current residents in the facility have the potential to be affected. The facility Administrator / Designee has reviewed all grievance forms for the last 30 days for any reportable incidents. Any reportable incidents were reported. This was completed by the administrator on 5/6/2025. Root Cause Analysis: Facility failed to follow the abuse, neglect, and exploitation policy to report an allegation of abuse within 2 hours of notification. Element 3: The Abuse, Neglect, and Exploitation policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The facility administrator was re-educated on the reporting guidelines of abuse by the Regional Director of Operations on 5/7/2025. The Director of Nursing / Designee has re-educated all current employees on the Abuse, Neglect, and Exploitation policy by 5/19/2025. Any current employee who is not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. All allegations of abuse and grievance forms are to be reviewed daily, Monday through Friday, in morning meetings and are to be reported by the facility. Element 4: The Administrator will audit up to 5 grievance forms weekly to ensure there are no reportable incidents. Audits will be weekly x4 weeks then monthly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Delayed Response to Change of Condition and Failure to Provide Medically Necessary Equipment
Penalty
Summary
The facility failed to timely address a change in condition for one resident who exhibited symptoms consistent with a urinary tract infection (UTI), including confusion, general weakness, increased urinary frequency, abdominal cramping, and pain during urination. Despite these symptoms being documented by nursing staff, there was a delay in collecting and processing the urine specimen, and antibiotics were not started until four days after symptom onset. The nurse practitioner did not initiate antibiotic treatment based on the resident's symptoms and chose to wait for culture results, even though the resident's condition continued to decline, with documented altered mental status, rapid heart rate, low oxygen saturation, and eventual transfer to the hospital for further evaluation. The Director of Nursing acknowledged that antibiotics could have been started earlier and that the delay should not have occurred. Additionally, the facility failed to ensure timely submission of medically necessary documentation for a power tilt recline wheelchair for another resident with quadriplegia, a traumatic brain injury, and a stage 4 pressure ulcer. The resident was dependent on a power wheelchair for mobility and pressure relief, but the process to obtain a customized wheelchair was delayed for nearly three months due to the facility's lack of follow-up on documentation requests from the equipment vendor. Multiple emails and voicemails from the vendor went unanswered, and the interim rehabilitation director did not submit the required paperwork while covering the department. The resident, who was cognitively intact, became distressed and frustrated by having to coordinate their own care and repeatedly advocate for the necessary equipment. The facility did not have a policy addressing timely assessment, monitoring, and treatment for a change of condition, and failed to provide a requested policy for rehabilitation services. The deficiencies resulted from lapses in communication, lack of timely clinical intervention, and inadequate follow-up on essential documentation, directly impacting the care and well-being of the residents involved.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Resident R905 appeal paperwork and supporting documentation for resident’s specialized wheelchair request has been sent to the vendor by the Director of Rehab on 5/1/2025. Element 2: Director of Nursing / designee reviewed last 7 days of Progress Notes for changes in condition being documented appropriately and timely and with proper notification. Any concerns identified were immediately addressed. Completed on 5/9/2025. Facility has reviewed all current residents that have been evaluated for a specialized wheelchair in the last 60 days to ensure all documentation has been completed timely and if appropriate wheelchair has been provided and care planned. Root Cause: Facility staff did not timely address a resident’s change in condition. Facility failed to submit additional necessary medical documentation timely to order a power wheelchair. Element 3: The Notification of Change policy and the Provision of Quality of Care policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The DON/Designee has re-educated all current nursing staff on Notification of Change policy by 5/14/2025. Any current nursing staff member not re-educated by 5/14/2025 will be re-educated prior to their next scheduled shift. The DON/Designee has re-educated the IDT team and the Rehab team on the Provision of Quality of Care policy by 5/19/2025. Any IDT team member or rehab staff member not re-educated prior to 5/19/2025, will be re-educated prior to their next working shift. The Medical Director has re-educated the Nurse Practitioner on Antibiotic monitoring and timeliness of follow-up. Completed by 5/19/2025. Element 4: The DON/Designee will audit all changes in condition daily, Monday - Friday, to ensure appropriate interventions are placed timely. Audits will continue daily for 4 weeks then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The DON/Designee will audit all specialized wheelchair requests weekly to ensure appropriate documentation is completed and submitted timely. Audits will continue weekly for 4 weeks then monthly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.
Delay in Laboratory Specimen Pickup Resulting in Untimely UTI Diagnosis
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who was experiencing symptoms suggestive of a urinary tract infection (UTI). The resident, who had a history of confusion, increased urinary frequency, abdominal cramping, and pain during urination, had a urine specimen collected for urinalysis and culture as ordered by a nurse practitioner. Despite the specimen being collected promptly, there was a delay in its pickup, as the laboratory did not retrieve the specimen for processing until two days after collection. Interviews with the Director of Nursing confirmed that the facility's standard procedure was for lab specimens to be picked up daily on weekdays, with the option for a stat pickup on weekends if needed. The Director acknowledged that there should not have been a delay between specimen collection and delivery to the lab. Additionally, the facility's policy on laboratory and diagnostic guidelines did not specify timeframes for collection, transportation, or reporting of lab results, contributing to the lack of timely laboratory services.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Element 2: All current residents identified with labs and diagnostic tests ordered over the last 14 days were verified as completed. Any concerns were immediately addressed. Completed by the Director of Nursing / designee on 5/7/2025. Root Cause: Facility failed to ensure timely follow up for lab services. Element 3: The Laboratory and Diagnostic Guidelines Policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The Director of Nursing / Designee has re-educated all current licensed nurses on the Laboratory and Diagnostic Guidelines Policy by 5/19/2025. Any current licensed nurse not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. Nurse managers will review the order listing report daily, Monday through Friday, in morning clinical meeting to ensure labs and diagnostics are completed as ordered. Element 4: The Director of Nursing / Designee will audit the order listing report daily, Monday through Friday, to ensure labs are completed as ordered. Audits will continue for 5 days per week x4 weeks and then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.
Failure to Report Abuse Allegation and Maintain Sufficient Staffing
Penalty
Summary
On the night in question, two residents with histories of alcohol dependence and cognitive impairment were found intoxicated together in one resident's room. One resident, who had severely impaired cognition and a BIMS score of six, reported being prevented from leaving the room and being inappropriately touched by the other resident. Staff responded to the resident's calls for help and found both individuals in the same bed, with evidence of alcohol consumption present. The incident was reported by a CNA to a nurse, and a quality assurance form was completed, but the administrator was not informed until days later, contrary to facility policy requiring immediate reporting of abuse allegations. The facility was experiencing a staffing shortage during the shift when the incident occurred, with only four nurses present instead of the required six. Staff reported being unable to provide adequate supervision for residents, particularly those with behavioral issues and high fall risks. As a result, multiple residents received their medications late, and supervision was insufficient to prevent or promptly address incidents such as the one involving the two intoxicated residents. Staff also indicated that the resident accused of inappropriate touching had a history of problematic behavior, including drinking and inappropriate interactions with other residents. Facility policies reviewed during the investigation required immediate reporting of abuse allegations and sufficient staffing to ensure resident safety and well-being. However, the failure to promptly notify the administrator of the abuse allegation and the inability to maintain required staffing levels led to delayed medication administration and inadequate supervision. These actions and inactions directly contributed to the deficiencies identified in the report.
Plan Of Correction
Weekend staffing will be reviewed on Friday in morning stand-up meeting. Any concerns will be addressed. Element 4: The Administrator will conduct a daily staffing meeting, Monday through Friday, to ensure that nurse staffing is sufficient to meet the residents' needs. Staffing meetings will be held daily, Monday through Friday, for four weeks, then weekly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Delay in Enteral Feeding Administration
Penalty
Summary
The facility failed to administer enteral tube feeding in accordance with a physician's order for a resident, resulting in a delay in receiving necessary nutrition and hydration. The resident, who was admitted following a severe accident that resulted in multiple bone fractures and a diffuse brain injury, required enteral feeding due to an altered nutritional state. Upon admission, orders were in place to administer Jevity 1.5 at a continuous rate of 60 ml per hour with a 25 ml water flush every hour. However, due to a delay in obtaining the necessary feeding pump, the resident did not receive the prescribed nutrition until 15 hours after admission. The Director of Nursing and the Registered Dietician reviewed the situation and confirmed that the supplies and formula were available as floor stock, but the facility was in the process of replacing their Kangaroo Pumps, which caused the delay. Despite the availability of the pump on the morning following admission, the nursing staff failed to document the administration of the feeding on the Medication Administration Record until two days later. The facility's policy on feeding tubes, which includes maintaining feeding tubes in accordance with clinical standards and using gravity flow if necessary, was not adhered to, leading to the deficiency.
Plan Of Correction
Element 1: Resident 906 no longer resides in the facility. Element 2: All current residents who are on tube feed have been audited to ensure tube feed is being administered appropriately as ordered. This was completed by the Director of Nursing / designee by 2/27/2025. Root Cause: Facility failed to ensure that tube feed orders were followed. Element 3: The Tube Feed policy was reviewed by the QAPI committee and deemed appropriate on 2/27/2025. The Director of Nursing / designee has re-educated all current licensed nurses on the Tube Feed policy by 3/6/2025. Any current licensed nurse not re-educated by 3/6/2025 will be re-educated prior to their next scheduled shift. Residents who admit to the facility with tube feed will be reviewed and assessed by the nurse at admission to ensure tube feed, pump, and other supplies are readily available. If not available at admission, DON and Medical Provider are to be notified for timely interventions to address resident's nutrition needs. Residents who admit to the facility with tube feed will be reviewed by the IDT team in clinical morning meeting daily, Monday through Friday, to ensure tube feed is administered timely and as ordered. Element 4: The Director of Nursing / designee will audit all admissions daily, Monday through Friday, to ensure that tube feed is being administered appropriately, orders are in place, care plan is updated, and tube feed administration is documented appropriately in the resident's record. Audits will be daily for 4 weeks then monthly thereafter until substantial compliance is achieved. The Director of Nursing / designee will audit all current residents receiving tube feed to ensure that tube feed is being administered appropriately, orders are in place, care plan is updated, and tube feed administration is documented appropriately in the resident’s records weekly. Audits will be weekly for 4 weeks then monthly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Failure to Prevent Falls and Ensure Timely Investigation
Penalty
Summary
The facility failed to ensure a timely investigation of a fall and provide appropriate supervision and interventions to prevent falls for two residents, resulting in one resident sustaining an acute subcapital left femoral neck fracture. The incident involved a resident with severe cognitive impairment who was found on the floor by a CNA during the night shift. The CNA, instead of immediately assisting the resident or notifying the nurse, texted a colleague who was on break. The resident was then improperly assisted back to bed without a proper assessment for injuries, and later complained of pain, which was not immediately addressed. The resident's medical record indicated a history of cognitive deficits, difficulty walking, and a need for assistance with daily activities. Despite these needs, the resident was not adequately supervised, and the facility staff failed to follow the care plan, which required a two-person assist for transfers. The staff involved did not document the fall or the resident's change in condition, and the nurse on duty was not informed of the incident, leading to a delay in assessing and addressing the resident's injuries. Another resident with a history of falls and cognitive impairment experienced multiple falls due to inadequate supervision and failure to implement recommended interventions. The resident's care plan was not updated to include necessary measures such as a 1:1 sitter, despite recommendations from a nurse practitioner. The facility's failure to provide adequate supervision and timely interventions contributed to the resident's repeated falls and injuries.
Deficient Call System in LTC Facility
Penalty
Summary
The facility failed to maintain an effective resident call system, which was supposed to alert caregivers directly. Observations and interviews revealed that the system relied on a monitor in the hallway, which staff had to check periodically to see if any call lights were on. There were no audible or visual alerts in the nursing work areas or outside resident rooms, and staff confirmed that they had no way of knowing if a resident needed assistance unless they checked the monitor. This system was used throughout the facility, affecting all 142 residents. Interviews with various staff members, including LPNs, RNs, and CNAs, confirmed the reliance on the hallway monitor to identify resident needs. Staff reported that they had to physically check the monitor to know if a resident required assistance, as there were no other alert systems in place. Some staff mentioned that pagers were previously used but were no longer available or functional, leaving the monitor as the sole method of notification. Residents expressed concerns about the call light response time during a resident council meeting, with reports of waiting over two hours for assistance. The facility's Administrator and Director of Nursing acknowledged the issues with the call light system, noting that staff had to check a central monitor to be aware of resident needs. Despite repeated concerns raised in resident council meetings, the facility had not implemented an effective alert system to ensure timely responses to resident needs.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure nursing staff adhered to professional standards of medication administration for three residents. For one resident, a prescription for Ciclopirox was found on their tray table, and the resident reported that staff usually administers the medication. However, there was no order for this medication in the resident's clinical record, and the Director of Nursing (DON) confirmed that medication should not be left in the resident's room without an assessment and proper storage. Another resident was observed with a medicine cup containing multiple pills on their bedside table, and the assigned LPN admitted to leaving medications for the resident to take without supervision, despite the resident not having an order to self-administer. Additionally, a nurse was observed improperly disposing of a liquid medication by pouring it down the drain, contrary to the facility's policy, which requires medications to be disposed of in a designated container in the medication room. The DON confirmed that medications should not be disposed of down the drain and should follow the proper disposal protocol. These observations indicate a failure to adhere to professional standards and facility policies regarding medication administration and disposal.
Failure to Provide Regular Showers and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in ensuring regular showers for a resident identified as R27. Observations and interviews revealed that R27, who was admitted with conditions including mixed incontinence, functional diarrhea, muscle weakness, and anxiety disorder, did not receive showers as scheduled. The resident reported that staff frequently postponed her requests for showers, leaving her hair saturated with sweat. A review of the Treatment Administration Record (TAR) indicated that R27 was supposed to receive a bath or shower twice weekly, but only four instances were documented over a 30-day period, with no refusals noted. Further observations on a subsequent day found R27 in bed with a soiled brief, indicating inadequate toileting hygiene. The resident had redness and a small open area in the groin folds and buttocks, which was noted by the wound team. The Director of Nursing (DON) confirmed the lack of documentation for the required showers and acknowledged the deficiency in care. The DON was unable to find additional records of showers or baths beyond those already noted, confirming the resident's allegations of not receiving regular showers.
Infection Control Deficiencies in PPE Use and EBP Implementation
Penalty
Summary
The facility failed to consistently adhere to infection control standards and protocols, as observed during a survey. Registered Nurse B and Certified Nursing Assistant C were seen exiting a resident's room with their PPE still on, contrary to CDC guidelines which require the removal of gloves and gowns before exiting and the removal of respirators after exiting. The Assistant Director of Nursing confirmed this was not the facility's protocol. Additionally, several rooms with residents on Droplet/Contact/Airborne precautions had their doors open, and RN B was observed using the same N95 mask and shield for multiple residents, which was against the stated protocol of changing N95s for each resident and sanitizing shields between uses. Another deficiency was noted with a resident who had a catheter drainage bag touching the floor, and there was a delay in implementing Enhanced Barrier Precautions (EBP) for this resident. The Infection Preventionist acknowledged the delay, citing a scabies and COVID-19 outbreak as the reason for not being able to address all residents requiring EBP promptly. The resident had been admitted with several diagnoses, including severe cognitive impairment, and required assistance with most activities of daily living. The EBP was not implemented until five days after the resident's admission, despite physician orders being in place.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for two residents, R16 and R124, as required. For R124, the facility did not complete an initial social service assessment within the first seven days of admission, leaving all text fields blank. R124, who has severe cognitive impairment due to dementia, did not have an appointed legal decision maker, and there was no documentation of any legal guardianship or power of attorney process being initiated. The Social Service Worker acknowledged the oversight and indicated that they were waiting for documentation from the family to establish power of attorney. For R16, who has a history of anxiety, depression, and suicidal behavior, the facility failed to ensure proper follow-up and documentation after a recent hospital visit for suicidal ideations. R16 was sent to the hospital after expressing a plan to leave the facility, which was interpreted as a suicide plan. Upon readmission, there was no documentation of a psychological evaluation, medication changes, or follow-up appointments. The Director of Social Work was unaware of any updates or interventions, and there was no evidence of 15-minute safety checks being implemented, despite R16's history and recent ideations. The facility's Social Services department did not adhere to its essential functions, which include performing resident assessments upon admission and condition changes, and updating care plans and progress notes. The lack of documentation and follow-up for both residents highlights a failure to provide necessary psychosocial support and intervention, as outlined in the facility's job description for social workers.
Medication Reconciliation Failure for Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation for controlled medications for two residents. On September 18, 2024, during an observation of the North Tulip medication cart with RN CC, it was found that a tablet of Hydrocodone/Acetaminophen was not administered to a resident as recorded. The narcotic binder indicated that one tablet was given at 2:26 PM, leaving five tablets remaining, but the blister pack showed only four tablets. RN CC admitted to being distracted by assisting another resident in an isolation room and forgetting to administer the medication. Additionally, on the same day, a review of the Back Mum medication cart with RN Y revealed a discrepancy in the narcotic binder for another resident. The binder showed that a tablet of Tramadol was last given on September 16, 2024, with 13 tablets remaining, but the blister pack contained only 12 tablets. RN Y acknowledged administering the tablet before dinner but failed to reconcile the medication in the binder. The Director of Nursing was informed of these discrepancies and acknowledged the facility's failure to ensure accurate reconciliation.
Failure to Complete Physician-Ordered Lab Diagnostics
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident, identified as R149, who was admitted with diagnoses including respiratory failure, hypoxemia, pulmonary emphysema, and pulmonary edema. On 7/11/24, a Nurse Practitioner evaluated R149 due to a chief complaint of shortness of breath and ordered a STAT CO2 level, CBC, and CMP. Despite these orders, a review of R149's medical record revealed no documentation that the CO2 level or CMP lab tests were drawn or that results were reported to the medical provider. On 9/17/24, the Director of Nursing (DON) was queried about the missing lab results and indicated they would investigate the issue. The following day, the DON confirmed that the orders for the CO2 level and CMP, which were ordered STAT on 7/11/24, were never completed, and no results were available. During the exit conference, the Administrator acknowledged an issue with laboratory diagnostics and mentioned that a past non-compliance (PNC) was completed, including facility audits and education. However, the report focuses on the initial failure to complete the ordered laboratory diagnostics for R149.
Failure to Provide Rehabilitative Services for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary rehabilitative services for a long-term resident, identified as R108, who was admitted with multiple diagnoses including contractures of both hands, dementia, and anxiety disorder. Despite being confined to bed and requiring extensive assistance with Activities of Daily Living (ADL), the resident did not receive periodic rehabilitation screening or evaluation. Observations revealed that R108's hands were consistently in a clenched position, and a palm protector carrot intended to prevent worsening of hand contractures was not being used by staff, as reported by the resident. The resident's Electronic Medical Record (EMR) indicated orders for evaluations by Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP), but there was no evidence of completed therapy screens or evaluations addressing the resident's needs. The Certified Nursing Assistant (CNA) daily task list did not include any maintenance program for range of motion or splinting, and there was no follow-up or education provided by occupational therapy. Interviews with staff, including a CNA and the Restorative Nurse, confirmed that R108 was not on a maintenance program since 2023, and no referral from OT had been received to initiate such a program. Further interviews with the Therapy Manager (TM) revealed that there was no process in place for routine screening or assessment of range of motion for residents with contractures. The TM acknowledged that R108 had been receiving OT services until August 2023, which were discontinued when the resident was signed up for hospice, although hospice services were later discontinued. The Director of Nursing (DON) was aware of the issue and had discussed it with the therapy manager, but the facility's rehabilitation therapy and services document only addressed Medicare residents and did not include all residents of the facility.
Failure to Administer Pneumonia Vaccine After Consent
Penalty
Summary
The facility failed to ensure the administration of the pneumonia vaccine to a resident who had consented to receive it. The resident, who was admitted with medical diagnoses including heart failure, hypertension, diabetes, high cholesterol, and dementia, was cognitively intact with a BIMS score of 14/15. The resident signed a consent for the pneumonia vaccine, but the Electronic Medical Record indicated that the vaccine was refused. An interview with the Infection Preventionist confirmed the documentation of refusal despite the consent, and the vaccine had not been administered. Corporate Clinical Services acknowledged the failure to administer the vaccine after consent was given.
Deficiency in Timely COVID-19 Vaccine Administration
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered and administered in a timely manner to two residents, leading to a deficiency in their immunization process. One resident, identified as R136, was admitted with multiple medical diagnoses including cancer and renal failure, and had a moderate cognitive impairment. The COVID-19 vaccine was not offered to this resident until a random sample review by the Infection Preventionist, who admitted that the resident had 'slipped through the cracks.' The facility policy required the vaccine to be offered within 72 hours of admission, which was not adhered to in this case. Another resident, R29, who had severe cognitive impairment and medical conditions such as hypertension and diabetes, consented to receive the COVID-19 vaccine but experienced a significant delay in administration. The vaccine was offered and consented to on one date, but not administered until nearly a month later. The delay was attributed to the need for insurance authorization, which typically does not exceed a week, indicating a lapse in follow-up. The Infection Preventionist acknowledged the oversight, and Corporate Clinical Services confirmed the failure to ensure timely vaccine administration after consent.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances reported by a resident, identified as R79, who was admitted with diagnoses including heart failure, diabetes, muscle weakness, mild cognitive impairment, and legal blindness. The resident had a BIMS score of 14/15, indicating mild cognitive impairment, and required assistance with activities of daily living. A complaint was received by the State Agency indicating that concerns brought to the facility's attention were not resolved in a timely manner. Specifically, the resident and their family reported missing personal items, including a sweater, neck pillow, and pillowcase, on 7/21/24. However, the facility did not address these concerns until an interdisciplinary team meeting on 8/16/24, 26 days later, and only the missing sweater was addressed. The facility's grievance process was found lacking as it did not document or follow up on other concerns related to medication administration, care, and ancillary service appointments that were communicated during the meeting. The facility's documentation did not reflect any investigation or follow-up on these issues, and the resident's electronic medical record did not contain any further documentation related to these concerns. An interview with the resident's family member revealed that they had attempted to follow up on these issues but only managed to speak with the social worker, not the administration, and did not receive any callbacks. They also reported that they had to take time off work to attend a meeting they were informed the administrator would attend, but the administrator was absent. Interviews with facility staff, including the Director of Social Work and the facility administrator, revealed inconsistencies in the grievance process. The Director of Social Work confirmed that the resident's concerns were discussed but not documented, and the administrator acknowledged the delay in addressing the grievances. The facility's grievance policy, revised on 1/1/22, lacked specifics on the process and timeframe for resolving grievances, stating only that complaints would be documented but no response was required. This lack of documentation and timely follow-up on grievances led to the deficiency identified in the report.
Failure to Obtain Timely Podiatry Care for Resident
Penalty
Summary
The facility failed to obtain a podiatry appointment for a resident, identified as R79, who was experiencing foot pain and swelling, and had ingrown toenails. R79, who had a history of diabetes, heart failure, and mild cognitive impairment, was admitted to the facility with a physician's order for a podiatry consult dated 8/6/24. Despite this order, there was no evidence in the clinical records that the consult was completed. The resident continued to experience foot issues, and a subsequent order for a podiatry consult was made on 9/17/24, indicating a delay of over 40 days since the initial order. Interviews with facility staff revealed that the appointments/transport coordinator was unaware of the initial order and had only received the order on 9/17/24. The coordinator mentioned that sometimes orders fall off the electronic medical record system. The Director of Nursing was also unsure why the initial order showed as completed without the resident having been seen by a podiatrist. The facility's failure to ensure timely podiatry care for R79, despite the resident's diabetic condition and ongoing foot issues, led to the deficiency noted in the report.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R149 and R112, as observed during a survey. For R149, the deficiency involved the lack of continued oxygen therapy administration as per the Nurse Practitioner's evaluation. R149 was admitted with diagnoses including respiratory failure and hypoxemia, and was initially placed on 2L oxygen via nasal cannula on 7/11/24. However, there was no documentation of continued oxygen therapy after this date, despite the NP's evaluation on 7/12/24 indicating the need for ongoing oxygen support. The Director of Nursing acknowledged the oversight and confirmed that an additional order for oxygen administration was missed. For R112, the deficiency was related to the provision of an inappropriate nasal cannula that did not fit properly, making it difficult for the resident to breathe. R112, who was admitted with chronic respiratory conditions and dependence on supplemental oxygen, reported the issue to the facility upon admission. Despite notifying the Director of Social Work and Central Supply staff, the facility failed to provide a suitable nasal cannula, forcing R112 to use their own supply. The Central Supply staff member considered the request a personal preference and delayed action, while the Director of Nursing was unaware of the need for regular nasal cannula changes due to the absence of an order. The facility's policy on oxygen administration requires changing oxygen tubing and cannulas weekly, but this was not adhered to for R112. The lack of an active order for changing the nasal cannula contributed to the oversight. Both cases highlight the facility's failure to follow physician orders and ensure appropriate respiratory care, leading to deficiencies in the care provided to residents R149 and R112.
Failure to Administer Scheduled Antipsychotic Medication
Penalty
Summary
The facility failed to administer a scheduled long-acting antipsychotic medication, Haldol Decanoate, to a resident, identified as R601, as per the prescribed schedule. The resident was supposed to receive the medication every two weeks, but the facility did not administer the dose due on 6/28/24. This lapse was discovered following a complaint that the missed injection led to an increase in the resident's mental health symptoms, deviating from her mental health baseline. The resident's Community Mental Health Case Manager (CMH CSM 'D') had delivered the first dose to the facility on 6/13/24, which was administered on 6/14/24. However, there was no documentation or evidence of efforts made by the facility to obtain the subsequent dose due on 6/28/24. The facility's Director of Nursing (DON) and RN 'C' acknowledged that there was no further communication or coordination with the CMH agency or pharmacy to secure the medication after the initial dose was administered. The resident was discharged on 6/29/24 without receiving the scheduled Haldol injection. The discharge summary and home care referral did not document the missed dose, and there was no indication that the facility attempted to address the issue before the resident's discharge. The facility's inaction and lack of coordination with the CMH agency contributed to the failure to administer the medication as prescribed.
Failure to Provide Required Assistance for Bed Mobility
Penalty
Summary
The facility failed to ensure the required assistance level for bed mobility was provided to a resident, leading to multiple falls. The resident, who was under hospice care and had a history of falls, was observed without assist rails or bars in place. The resident reported that they rolled out of bed while a single aide was changing their brief and linens, despite the care plan indicating that two-person assistance was required for bed mobility and toileting. The resident had moderately impaired cognition and required substantial assistance with daily activities, including bed mobility. The clinical record revealed that the resident had been hospitalized and returned to the facility following a fall incident that resulted in a closed head injury. The resident's care plan included interventions such as a body pillow for bed boundary awareness and frequent rounding to ensure proper positioning. However, the facility did not identify that the aide was providing care alone when two-person assistance was required. The aide involved in the incident reported not being aware of the two-person assistance requirement and had not received adequate training on checking residents' care needs. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Regional Director of Operations, revealed a lack of proper documentation and follow-up on the incident. The DON, who was new to the role, was unaware of the specific care requirements and interventions needed to prevent falls. The facility's policy on accidents and supervision emphasized the need for individualized care plans, but this was not effectively implemented in the resident's case, leading to repeated falls and injuries.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident with diagnoses including major depression, chronic respiratory failure, and diabetes. Specifically, a skin scraping order from January 30, 2024, to rule out scabies was not completed. Despite multiple inquiries and a review of the resident's clinical record, the facility was unable to provide the results of the skin scraping test. Interviews with the infection preventionist and the Director of Nursing revealed that the facility's process for ensuring laboratory orders are executed involves discussing diagnostic testing orders in morning meetings and having the ordering provider follow up during their rounds. However, no explanation was provided for why the specific order from January 30, 2024, was not completed. The Nursing Home Administrator also confirmed that they were unsuccessful in locating the results for the skin scraping order. The facility's Laboratory and Diagnostic Guidelines policy mentions various methods for tracking laboratory and diagnostic tests, including tracking logs, electronic portals, and calendars. Despite these guidelines, the facility did not complete the skin scraping order, and no results were provided by the conclusion of the survey.
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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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