Medilodge Of Montrose Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, Michigan.
- Location
- 9317 West Vienna Road, Montrose, Michigan 48457
- CMS Provider Number
- 235600
- Inspections on file
- 36
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Medilodge Of Montrose Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, incontinence, and a history of coccygeal skin issues developed a red area on the coccyx that was identified by CNAs and treated with zinc oxide per nursing orders over several weeks, yet nurses and the wound care nurse failed to complete and document detailed skin assessments or progress notes describing the area’s condition. Weekly skin assessments repeatedly recorded no abnormal skin areas despite ongoing treatment and CNA charting of red and discolored skin, and staff interviews revealed reports of a very red, peeling, and leaking bottom as well as inconsistent incontinence care at night. On the rushed day of discharge, no body skin assessment was performed, the discharge summary inaccurately stated there were no skin issues, and the receiving facility and family immediately observed extensive redness, open and weeping areas from the lower back to the legs, leading to hospital transfer where the resident was diagnosed with a large area of cellulitis and treated with IV antibiotics, with hospital documentation noting a high suspicion of elderly neglect.
A resident with multiple chronic conditions, who was cognitively able to make his own decisions, reported that he had loaned a CNA $500 in cash under a verbal repayment agreement that was not being honored, and later described difficulty getting the money repaid. Another CNA overheard the resident and the CNA arguing about the unpaid balance, and the Social Work Director reported that the resident had alleged misappropriation of funds. The Administrator was informed of the situation on several occasions by different staff but did not initiate a facility-reported incident or report the matter to the state, asserting there was no proof and no allegation of theft, despite facility policy and staff training that prohibit staff from accepting or borrowing money from residents and require reporting of alleged violations.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall that was not promptly reported or assessed by staff. CNAs found the resident on her knees and noted a knee abrasion but did not clearly communicate the incident as a fall to the nurse, who then failed to initiate the fall protocol. The event was not documented until days later, after family members noticed injuries and raised concerns, resulting in delayed assessment, monitoring, and notification.
A resident with multiple complex medical conditions was admitted with an indwelling urinary catheter, but the facility did not obtain a physician's order for the catheter or document appropriate monitoring and care. Nursing records lacked orders for catheter care, changes, or securement, and there was no evidence of ongoing assessment or documentation by staff.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. This deficiency reflects a lack of adequate safeguards to ensure resident safety.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to individualized care.
The facility did not ensure that a resident had access to both routine and 24-hour emergency dental care, resulting in unmet dental needs.
A resident did not receive appropriate care for pressure ulcers, and necessary measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
Multiple residents experienced significant delays in call light response, inconsistent assistance with ADLs, and unmet care needs, including incontinence care and snack distribution. Residents reported staff inattentiveness, malfunctioning call lights, and prolonged waits for help, with some left in soiled bedding or without access to a functioning call system. Facility records and interviews confirmed repeated failures to respond promptly to resident requests, in violation of facility policy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal, and failed to establish or implement a grievance policy or promptly resolve complaints.
Multiple residents did not receive consistent assistance with ADLs such as bathing, grooming, and nail care, despite being unable to perform these tasks independently. Residents reported missed showers, unaddressed requests for personal hygiene, and long call light response times, with staff often failing to follow up or document refusals. Facility policies requiring routine ADL and nail care were not consistently implemented, and residents' preferences were frequently disregarded.
Multiple residents experienced extended call light response times and unmet needs due to non-functional or inaccessible call light systems. Observations included call lights out of reach, malfunctioning call light cords, and staff not carrying pagers. The central monitoring screen for several halls was also inoperable for months, leaving staff unaware of resident calls. These deficiencies resulted in residents being unable to obtain timely assistance with personal care and other needs.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that staff education records were falsified, with several CNAs and nurses reporting they had not completed required online modules despite records showing completion. The SDN admitted to possible errors in documenting education, and the DON could not clarify who had access to the system. This resulted in staff being marked as trained in critical areas such as infection control and resident rights without actually completing the education.
Surveyors found that staff did not follow infection control practices or ensure emergency equipment was available for residents with tracheostomies and oxygen needs. For example, a resident's oxygen tubing was found on the floor and reattached without replacement, emergency trach equipment was not at the bedside, and supplies such as suction canisters and distilled water were undated. Care plans lacked documentation of trach size, and oxygen orders were incomplete, all in violation of facility policy.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unattended after staff failed to respond to a door alarm. The resident's care plan was not updated to reflect elopement risk, and staff did not consistently carry pagers to receive door alerts, resulting in delayed response and lack of timely documentation of the incident.
Multiple residents experienced delayed responses to call lights, with some waiting over 30 minutes or being unable to reach their call light, leading to frustration and incontinence. Residents also reported not receiving meals or snacks as ordered, receiving cold or incorrect food, and having their dietary preferences ignored. Environmental needs, such as adequate lighting, were not consistently met, and staff interviews confirmed lapses in following facility policies regarding resident dignity and preferences.
A resident with severe cognitive impairment and multiple medical conditions was found with vaginal bleeding and swelling, and exhibited distress during care. Staff notified the DON and provider, leading to hospital transfer, but did not communicate suspicion of abuse to administration. The hospital initiated a rape test and notified police, prompting the facility administrator to learn of the potential abuse only after police arrived. The State Agency was not notified until the following day, resulting in delayed investigation and assessment of other residents.
The facility did not accurately update or post daily nurse staffing information as required, resulting in discrepancies between the posted BIPA forms and actual staffing schedules. The DON confirmed that new staff were not properly coded, leading to incorrect staffing information being displayed for all residents, staff, and visitors.
The facility failed to provide and document ADL and hygiene care for five residents, leading to concerns about inadequate staffing and care. Residents were often found in bed with unkempt appearances, and there was a lack of documentation for bathing and oral hygiene. The DON confirmed the lack of documentation and suggested that staff might not be documenting the care provided.
The facility's short-term units experienced a failure in the call light system, affecting the 100, 200, 300, and 400 hallways. Observations and staff interviews revealed the absence of a central monitoring screen and visual indicators, with pagers either unavailable or delayed. Staff relied on frequent room checks to assist residents, as the system had been non-functional for about a month. The administration acknowledged the issue, and the Maintenance Director noted challenges in programming replacement pagers.
A resident with severe cognitive impairment and dependency on staff experienced a change in condition that was not promptly assessed or documented by the nursing staff. Despite signs of respiratory distress, the nurse failed to apply necessary interventions, such as oxygen, and left the resident unattended. The delay in calling a code and initiating emergency measures contributed to the deficiency, as confirmed by interviews with facility staff and management.
The facility failed to maintain and label tube feeding equipment properly for several residents, leading to deficiencies in care. Observations revealed issues such as unlabeled solution bottles, inaccurate feeding volumes, and improper dressing management. The DON and other staff acknowledged these issues, indicating lapses in adherence to physician orders and facility policies.
The facility failed to provide proper respiratory care for several residents, including incorrect oxygen settings and poor management of trach supplies. A resident was found with an empty oxygen tank, while another had their oxygen set at a lower rate than ordered. Two residents with tracheostomies had improper oxygen settings and inadequate trach care, with one resident's suction canister nearly full. Another resident's oxygen was set higher than ordered, and their CPAP and nebulizer masks were not properly used or stored.
The facility failed to conduct yearly competency evaluations for RNs, LPNs, and CNAs, as identified during a survey. Six out of seven staff members reviewed lacked current evaluations for 2023 or 2024. The HR Personnel confirmed the absence of these evaluations, noting they were not completed by the previous administration. The DON acknowledged the issue and stated that evaluations were in progress with Unit Managers.
The facility failed to maintain accurate and updated nurse staffing records as required by BIPA, with discrepancies observed in the posted hours for RNs, CNAs, and LPNs. The Scheduling Coordinator acknowledged inconsistencies in the records, including missing days and conflicting data, which affected the ability of residents, their representatives, and visitors to determine the nursing staff on duty.
The facility failed to properly store and label medications, with surveyors finding loose tablets and undated multi-dose medications in several medication carts. Additionally, discrepancies in narcotic reconciliation were observed, including incorrect documentation and scribbled numbers on count sheets. The Director of Nursing acknowledged these issues, indicating a systemic problem in medication management.
The facility failed to update care plans for two residents, leading to potential unmet care needs. One resident had a urinary catheter without a care plan for monitoring, despite a history of UTIs. Another resident was prescribed Clonazepam without documented risk versus benefits or education, and the care plan lacked monitoring interventions. These deficiencies reflect a lack of adherence to care planning and psychotropic drug policies.
A resident with hypertension was administered Metoprolol despite physician's orders to hold the medication if certain blood pressure and heart rate parameters were not met. The MAR showed repeated and identical vital sign entries over several months, indicating a failure to take new readings at the time of administration. The DON confirmed that the facility's policy required obtaining and recording vital signs when parameters were specified.
The facility failed to provide adequate nail and denture care for two residents, leading to potential risks for embarrassment, skin injury, and infection. One resident had long, jagged nails and old nail polish, with no interventions for nail care refusals. Another resident's denture cup contained debris, indicating a lack of proper cleaning. Facility policies on ADL and nail care were not followed, as routine cleaning and inspection were not provided as needed.
A facility failed to coordinate hospice services for a resident with a terminal prognosis, lacking up-to-date documentation and comprehensive care. Another resident, recently admitted after sepsis, had inadequate wound care, with saturated bandages and soiled sheets observed. Facility policies on wound treatment and hospice coordination were not followed, leading to deficiencies in care.
A resident experienced a decline in range of motion and developed contractures due to the facility's failure to conduct a thorough initial therapy assessment and adhere to its range of motion policy. The resident, who was previously able to walk with a cane, reported that therapy had not attempted to stand him up. Medical records revealed that baseline range of motion was not comprehensively assessed upon admission, and contractures were not noted. The facility did not place the resident on a restorative program, leading to a decline in mobility and the development of contractures.
The facility failed to manage urinary catheters and UTIs for three residents, leading to potential complications. A resident's catheter bag was improperly placed on the floor, with no physician order or documentation for the catheter. Another resident had recurrent UTIs with no antibiotic sensitivity provided, complicating treatment. A third resident's catheter was on the floor, with no care plan or physician order for its continued use.
The facility failed to respond to pharmacy recommendations for two residents regarding unnecessary medications. For one resident, the facility did not respond to three out of four pharmacy recommendations, including lab tests and correcting an antibiotic administration route. For another resident, the facility did not document or sign off on recommendations for discontinuing medications and monitoring orders. The facility's DON confirmed that recommendations were not accessible in the medical record prior to October 2024.
A facility failed to provide a risk versus benefits analysis and medication education to a resident or their responsible party before administering clonazepam for anxiety. The resident, who was cognitively impaired and had multiple medical conditions, was given the medication without appropriate documentation. The facility's policy requires such documentation and education, but it was not completed, and attempts to contact the resident's wife for consent were made only after the surveyor's inquiry.
A resident with dementia and severely impaired cognition was served a lunch meal that did not align with their documented food preferences, including dislikes for mashed potatoes and gravy. Despite an intervention to honor food preferences, discrepancies in meal tickets were noted, with conflicting alerts added by speech therapy. The resident expressed dissatisfaction with the meal, highlighting a failure in accommodating dietary preferences.
A nurse failed to follow proper medication administration procedures by using a soiled pill cutter and handling pills with bare hands before administering them to a resident. The Infection Control Nurse confirmed that this practice was against the facility's policy, which requires medications to be handled without direct contact and equipment to be clean.
The facility failed to obtain lab results before starting antibiotics for two residents, potentially affecting all residents. One resident received Cephalexin for a possible UTI without lab results or symptoms, while another was prescribed Cefdinir without antibiotic sensitivity testing. The facility's infection surveillance data showed a high rate of UTIs and antibiotic use, with many residents treated multiple times without proper testing.
A facility failed to implement a care plan for a resident with impaired hepatic status, leading to hospitalization. The resident, with a complex medical history, was not monitored for abdominal girth or pain location as required by the care plan. This deficiency was acknowledged by nursing staff and resulted in the resident's ICU admission for conditions including pancreatitis and liver cirrhosis.
A resident with a history of mental illness did not receive necessary mental health services at the facility, resulting in a major psychotic episode and hospitalization. The facility failed to contact the resident's previous mental health provider and did not make timely referrals for mental health services. A referral to Behavioral Care Solutions was prepared but never sent, and the resident's Haldol medication was discontinued without titration.
A long-term care facility failed to implement necessary infection control measures after a resident tested positive for Legionella. Despite repeated requests from the Health Department, the facility did not conduct timely water testing, collect samples from symptomatic residents, or implement recommended infection control practices. This inaction placed residents, staff, and visitors at risk of exposure to Legionellosis.
A resident with multiple health issues experienced a decline in condition, including difficulty breathing and low oxygen levels, while in a facility. Despite having orders for continuous oxygen therapy, records showed inconsistencies in its administration. Blood glucose monitoring was also inconsistent, and there was a lack of documentation for interventions. The facility's policies on change notification and oxygen administration were not followed, leading to the resident's transfer to the hospital and subsequent hospice care.
A resident in the facility received Gabapentin at incorrect times, with doses administered too closely together and too far apart, contrary to the prescribed schedule. The resident, who has multiple health conditions, reported the issue, and a review of the MAR confirmed the irregular administration. The DON acknowledged the problem, noting that the medication should not have been given so closely together.
A resident with multiple health issues fell and sustained a serious knee laceration due to inadequate supervision and assistance. The care plan required assistance for mobility, but the resident was found on the floor with no staff witnessing the fall. The incident was not investigated, and the standard of care was not met. The resident was hospitalized and later passed away due to complications.
A resident with cognitive impairment and behavioral issues engaged in multiple incidents of verbal and physical abuse towards other residents over nearly two years. Despite care plans and investigations, the facility failed to substantiate abuse or take adequate measures to prevent further incidents, ultimately discharging the resident to an AFC home.
A resident experienced significant distress due to a 24-hour delay in receiving her prescribed antianxiety medication, alprazolam, upon admission. The facility faced ongoing issues with timely pharmacy deliveries of controlled substances. Despite the resident's visible distress and repeated requests, the facility did not provide documented comfort measures or alternative interventions, leading to a violation of her rights to dignity and self-determination.
A resident with chronic conditions and unstageable pressure ulcers experienced inadequate care, leading to chronic wound contamination and worsening ulcers. Observations showed improper use of pressure-relieving devices and frequent soiling of wounds due to incontinence. Despite having a specialty mattress, the facility failed to ensure consistent pressure relief and did not update the care plan with specific instructions. Interviews confirmed a lack of proper training and care planning for pressure ulcer management.
A resident requiring tracheostomy care was observed being suctioned by an LPN who did not use sterile gloves, contrary to the facility's policy. The facility's Infection Control and Nurse Educator confirmed the requirement for sterile technique, and the DON acknowledged the issue. A discrepancy was noted between the facility's policy and a vendor's checklist regarding glove use.
Failure to Assess, Monitor, and Accurately Report Resident Skin Condition Resulting in Hospitalization for Cellulitis
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect of a resident by not adequately assessing, monitoring, and documenting a known skin condition, and by inaccurately reporting the resident’s skin status at discharge. The resident had multiple significant diagnoses, including vascular dementia, hemiplegia, and a prior history of a coccygeal pressure ulcer that had reportedly healed months earlier. A quarterly assessment showed a BIMS score of 2/15, indicating severe cognitive impairment. Despite this, the resident’s care plan identified risks related to incontinence and impaired skin integrity, with interventions directing staff to observe for redness or breakdown, provide peri-care after incontinence episodes, apply barrier cream, and notify nursing and the physician of new skin issues. A CNA documented a new red skin area on the resident on 01/01/2026, triggering an alert note on 01/02/2026. The wound care nurse documented only that there were “no areas of concern noted at this time,” without describing the location, appearance, or size of the new skin problem, and without a detailed skin assessment note. On 01/04/2026, a nurse entered an order for zinc oxide ointment to be applied to the coccyx twice daily and as needed for a red area, and the MAR shows this treatment was documented as given 63 times from early January through the resident’s discharge on 02/05/2026. However, there were no supplemental progress notes or skin assessments describing the coccygeal area’s condition, progression, or resolution, and weekly skin assessments repeatedly documented “no new” and “no existing” abnormal skin areas, despite the ongoing treatment order for a red coccyx. CNA point-of-care charting in February continued to note red and discolored skin areas, marked as not new, but these findings were not reflected in nursing skin assessments. Interviews with staff and others further demonstrated inconsistent recognition and follow-through on the resident’s skin condition. The resident’s former roommate reported that at night CNAs would sometimes only ask if the resident was wet and, if he said no, would not check or change him, resulting in the resident “sitting in piss.” CNAs who provided care stated that the resident’s bottom was very red, with dead skin and leaking fluid, and that nurses were aware and applying treatment creams, but they could not specify what was reported or when. Nurses recalled the resident having eczema and dry skin, and one nurse acknowledged the coccyx was red but not open, yet no detailed assessments were documented. The wound care nurse stated that she did not follow blanchable redness and did not document an assessment beyond the alert note. On the day of discharge, the discharge was described as rushed, no body skin assessment was performed, and the nurse completing the discharge summary documented “no skin issues noted” in the nursing skin/wound section. The receiving facility and family, upon assisting the resident to the restroom shortly after arrival, observed extensive redness from the lower back to the legs, open and weeping areas on the buttocks, and bloody fluid on the brief, leading to hospital transfer where the resident was diagnosed with a large area of cellulitis on the lower back and suspicion of elderly neglect. The hospital records documented redness along the sacral region extending to the back, excoriation throughout the coccygeal region, hyperemia, satellite lesions compatible with possible fungal infection, and evidence of secondary infection. Laboratory results showed an elevated white blood cell count, and the resident reported pain at 10 out of 10. The resident required IV antibiotics, antifungal cream, and narcotic pain medication during a five-day hospitalization and was discharged with continued oral antibiotics. The facility’s own abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm and pain, and job descriptions for RNs and LPNs required assessment, documentation of resident condition and nursing needs, and documentation of treatments and pertinent observations. Despite these requirements, the facility did not complete or document adequate skin assessments after a new skin concern was identified, did not ensure appropriate treatment follow-up and monitoring, and inaccurately documented that there were no skin issues at discharge, while the resident’s skin condition had progressed to cellulitis requiring hospitalization. Family members and the evaluating agency reported that they had not been informed of any ongoing skin issues prior to discharge and that the discharge paperwork and verbal report from the facility indicated no skin problems other than use of barrier cream. The family and receiving facility staff were shocked by the condition of the resident’s skin upon arrival, and the hospital documented a high suspicion for elderly neglect. The DON, upon review of the records, acknowledged that the wound care alert note lacked essential information, that the coccyx area being treated was not documented in skin assessments, and that there was no documentation to show whether the skin condition improved, worsened, or resolved from the time it was first identified until discharge. This sequence of incomplete assessment, lack of monitoring and documentation, and inaccurate discharge information constituted the neglect that led to the resident’s hospitalization for cellulitis and treatment with IV antibiotics. The facility’s own policies and staff job descriptions required prevention of neglect, ongoing oversight, and documentation of resident conditions and treatments. However, the record shows that after the CNA’s initial identification of a new red area, the wound care nurse did not document a detailed assessment, nurses did not create progress notes describing the coccygeal skin condition despite repeatedly applying treatment, and weekly skin assessments failed to acknowledge any abnormal skin areas. On the day of discharge, no skin assessment was performed, yet the discharge summary stated there were no skin issues. These actions and omissions, combined with reports of inconsistent incontinence care and the subsequent findings at the receiving facility and hospital, demonstrate that the resident was not protected from neglect related to skin care and monitoring.
Failure to Report and Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to implement policies and procedures to ensure reporting and investigation of a reasonable suspicion of a crime, specifically an allegation of misappropriation of a resident’s money by a CNA. A resident, who was his own decision-maker and able to clearly articulate his needs, reported that he had loaned a CNA a total of $500 in cash over a weekend, with a verbal agreement that she would repay him every paycheck. He stated that the CNA initially repaid only $30 and that he became upset when she did not abide by their agreement, although she later returned the remaining $470. The resident’s medical record, which included diagnoses of diabetes, atrial fibrillation, hypertension, chronic kidney disease, anxiety disorder, and major depressive disorder, contained no documentation of any allegation or follow-up regarding misappropriation of money. Another CNA reported overhearing the resident and the CNA arguing in the resident’s room with the door closed, during which the resident yelled that the CNA had agreed to pay him $30 every pay period and had not done so, and that she had until the end of the week to pay the balance or he would report the incident to the Administrator. The CNA who left the room was observed to be visibly crying. The Social Work Director stated that around December the resident had described loaning money to a “good employee” to pay a ticket, with payment arrangements that were not being honored, and that she informed him she would have to report this allegation to the Administrator/Abuse Coordinator. She stated the resident reported misappropriation of funds and it was assumed this was reported to the State Agency. The Administrator acknowledged being informed of the situation multiple times but did not treat it as a reportable allegation of misappropriation. He stated that initially the Social Work Director told him the resident had given money to an employee but would not provide the staff name, and that at that time the resident was not alleging theft. He also learned at a resident council meeting that the resident had loaned money to an employee with payment terms, and later received a phone call from a nurse again informing him that the resident had loaned money to the CNA, but he did not ask the nurse for further details. The Administrator stated there was no proof of the transaction and no allegation of misappropriation, and therefore no Facility Reported Incident was submitted to the state agency, despite the facility’s abuse, neglect, and exploitation policy defining an alleged violation as any observed or reported situation that, if verified, could indicate noncompliance with federal requirements. Staff, including the Staff Development Coordinator, confirmed that it was against company policy for staff to accept or borrow money from residents.
Failure to Timely Report, Assess, and Monitor Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical conditions experienced an unwitnessed fall that was not promptly reported, assessed, or documented by facility staff. The resident was found on her knees at the side of her bed by CNAs during shift change, and although the CNAs assisted her into her wheelchair and informed a nurse about a knee abrasion, they did not explicitly report the incident as a fall. The nurse, upon being notified, did not recognize the event as a new fall and therefore did not initiate the facility's fall protocol, which includes immediate assessment, documentation, and notification of the provider and responsible party. The lack of clear communication and understanding among staff led to a delay in recognizing and responding to the fall. The incident was not documented as a fall until several days later, after the resident's family noticed new injuries and raised concerns with facility leadership. During this period, required post-fall assessments, monitoring, and notifications were not completed. The resident's medical record did not reflect the fall or the resulting injuries in a timely manner, and the facility's point-of-care documentation failed to note any new skin issues or injuries during routine checks. Interviews with staff revealed confusion about the reporting process and a lack of awareness regarding the resident's fall. The nurse involved believed the knee injury was related to a previous incident and did not initiate the necessary protocols. The delay in identifying and reporting the fall resulted in a lack of comprehensive assessment and monitoring for the resident, as well as delayed notification to the provider and family. The deficiency was identified through a combination of family complaints, staff interviews, and record reviews, which confirmed that the facility failed to ensure timely reporting, notification, comprehensive assessment, and continued post-fall monitoring following the unwitnessed fall.
Failure to Obtain Physician Order and Monitor Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for one resident who was admitted from a hospital with the catheter in place. Upon review, there was no physician's order for the urinary catheter documented in the resident's records, including the physician order recap report, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the relevant months. Additionally, there was no documentation of monitoring or care for the urinary catheter, no order for when to change the catheter, and no order for a catheter securement device. The care plan did note catheter care, but this was not supported by corresponding physician orders or nursing documentation. The resident in question had multiple medical diagnoses, including atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis, and lymphedema. Despite these complex conditions and the presence of an indwelling catheter upon admission, the facility did not ensure that a physician's order was obtained or that appropriate monitoring and documentation of catheter care occurred. The Director of Nursing confirmed that a physician's order was required for the catheter and its discontinuation, and that monitoring should have been documented by nursing staff.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with established directives and the expressed wishes or objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for each resident as required. This deficiency indicates that residents did not have access to necessary dental services, both for regular care and urgent dental needs, as observed by surveyors during the review.
Failure to Provide Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor findings that indicated lapses in the care provided to residents at risk for or experiencing pressure ulcers. The report notes that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented, as required by care standards.
Failure to Ensure Timely Call Light Response and Resident Care
Penalty
Summary
The facility failed to ensure timely response to call lights and assistance with care needs, snacks, and incontinence care for multiple residents. During a Resident Council meeting, all attendees reported excessive delays in call light response, with some residents stating that grievances were not resolved and that staff were often inattentive, distracted by personal cell phones, or socializing with each other. Residents also reported inconsistent distribution of snacks and assistance with activities of daily living (ADLs), such as showers and incontinence care, with one resident stating she had not received a shower in over a month since returning from the hospital. Specific incidents included a resident with burns and a PICC line who waited 55 minutes for a nurse to respond to a beeping IV pump alarm, ultimately having to silence the alarm himself. This resident also experienced delays in wound care and reported that a nurse refused to change his dressing, stating it was not her job. Documentation showed that staff sometimes turned off call lights without meeting residents' needs, and not all staff received education or corrective action following these incidents. Other residents reported waiting over 30 minutes for call light responses, with one resident left without a functioning call light and another left on the toilet for nearly 50 minutes waiting for assistance. Facility records, including alarm event reports, confirmed multiple instances where call lights and bed exit alerts went unanswered for extended periods, sometimes exceeding an hour. Residents described being left in soiled briefs and wet bedding overnight, and one resident had to call the front desk for help when the call light system failed. Interviews with staff and the state ombudsman corroborated these findings, noting that staff sometimes entered rooms only to turn off call lights without providing the requested assistance. The facility's own policy required prompt call light response and staff education, but these standards were not consistently met.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints.
Failure to Provide Consistent ADL Assistance and Honor Resident Preferences
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including bathing, grooming, nail care, and personal hygiene, for multiple residents who were unable to perform these tasks independently. Several residents, all with varying degrees of cognitive and physical impairment, were observed to have unmet personal care needs such as unshaven facial hair, long and unclean fingernails, and infrequent or missed showers. In one instance, a resident reported that he relied on his daughter to shave him because the facility did not have enough razors, and although he requested assistance from staff, it was not provided. Another resident stated he had only received three showers during his entire stay and that staff never offered to clip his nails, which he disliked being long and unclean. Resident Council meeting minutes and interviews revealed ongoing, unresolved concerns among residents regarding inconsistent shower schedules, lack of adherence to personal care preferences, and delayed call light responses. Residents described staff as inattentive, often preoccupied with personal cell phones or socializing with each other rather than responding to resident needs. Specific complaints included not receiving scheduled showers or bed baths, being left in soiled incontinence briefs for extended periods, and staff failing to follow up on requests for personal hygiene assistance. Documentation for ADL care, such as shower sheets, was often missing or incomplete, and there was a lack of evidence that refusals of care were properly documented or followed up by nursing staff. Facility policies reviewed indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene, and that nail care should be routinely provided during ADL care. However, interviews with staff and review of records showed that these policies were not consistently followed. Residents repeatedly reported that staff cited lack of time as a reason for not providing nail care or showers, and there was no documentation of alternative arrangements or follow-up when care was missed. The facility also failed to make information about the Manager of the Day accessible to residents, limiting their ability to report unresolved issues.
Failure to Maintain Operational and Accessible Call Light System
Penalty
Summary
The facility failed to maintain a consistently operational and accessible call light system for multiple residents across several halls, resulting in extended call light response times and unmet resident needs. Observations revealed that call lights were not always within reach of residents, with one resident found with the call light apparatus touching the floor and not accessible, despite care plans specifying that the call light should be attached to the resident's clothing. Family concerns were documented regarding residents being left without call lights and having to call out for help without staff response. Several residents reported that their call lights were not functioning properly, with one resident demonstrating to the surveyor that the call light did not activate consistently, requiring multiple attempts before it worked. This resident also reported having to call the front desk for assistance when the call light failed. Another resident stated that their call light was not working for several days after admission, and only after reporting the issue did they receive a replacement cord. Multiple residents described slow or absent staff responses to call lights, with documented response times frequently exceeding 30 minutes and, in some cases, over an hour. Staff interviews revealed that the call light system relied on pagers and a central computer screen to alert staff to resident needs. However, several staff members did not have pagers on their person, and the central computer screen for several halls was not functioning and had not been operational for months. The maintenance director confirmed the screen had been out of service since their employment began. Without functioning pagers or the central screen, staff would not be aware of active call lights. These failures directly contributed to residents' needs going unmet, including assistance with toileting and other personal care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Falsification of Staff Education Records
Penalty
Summary
Surveyors identified that the facility falsified documentation regarding the completion of required online education for staff, potentially affecting all 112 residents. Multiple staff members, including nurses and certified nursing assistants (CNAs), reported during interviews that they had not completed the mandatory online education modules due to issues such as lack of access, inability to log in, or not receiving login credentials. Despite these statements, facility records indicated that these staff members had completed most or all of the required education modules on the same day. Further investigation revealed that the Staff Development Nurse (SDN) acknowledged possible errors in recording education completion, including the possibility that education modules were marked as completed for staff who had not actually participated. The SDN was unable to verify when or if staff had accessed the education program and admitted to entering education completion for others during orientation, which may have resulted in inaccurate records. One CNA, upon logging into the system for the first time, found all modules marked as completed despite never having accessed the program before. The Director of Nursing (DON) and SDN were questioned about who had access to the education system and how the documentation was completed, but could not provide a clear explanation. A review of facility policy confirmed the requirement for staff to demonstrate competency through education. The falsification of education records meant that staff may not have received necessary training in areas such as infection control, emergency preparedness, and resident rights, as required by facility policy.
Failure to Follow Infection Control and Emergency Equipment Protocols for Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control practices and ensure the availability of emergency equipment for residents with tracheostomy and oxygen care. For one resident, staff were unable to locate a replacement tracheostomy tube at the bedside, and the oxygen tubing was found on the floor, disconnected from the trach collar, resulting in the resident not receiving oxygen at the time of observation. Staff placed the contaminated tubing back onto the resident's trach, and no replacement tubing was available in the room. Emergency trach equipment was eventually found on a shelf behind the phone, not at the head of the bed as required. Another resident was observed without emergency trach equipment at the head of the bed, and the oxygen tubing was kinked, potentially obstructing oxygen flow. The distilled water for oxygen use and the suction canister were not dated, and the canister contained discolored secretions. In a third resident's room, after the resident had been transferred to the hospital, the suction canister with secretions and the opened distilled water were both undated. In a fourth resident's room, oxygen tubing was found stored in a basin on the floor, and there was no storage bag available for the tubing, contrary to facility policy. Medical record reviews revealed that care plans for residents with tracheostomies lacked documentation of trach size, and oxygen orders were incomplete or missing key details such as route and duration. Facility policies required that replacement trach tubes be readily available and that oxygen delivery devices be kept covered and changed if contaminated, but these practices were not followed for the residents reviewed.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unattended. The resident, who had diagnoses including dementia, metabolic encephalopathy, bipolar disorder, and unsteadiness, was found outside the building on the front porch in a wheelchair without staff supervision. Video footage confirmed that the resident exited through the front doors after visitors left, triggering the door alarm, but staff did not respond to the alarm. The resident was outside for several minutes before being brought back inside by the DON, and there was no immediate documentation of the incident in the resident's medical record. Further review revealed that the resident's care plan was not updated to reflect his exit-seeking behaviors, despite multiple documented instances of such behavior in the medical record. The social services department was unaware of the resident's elopement risk, and the resident was not included in the elopement risk binder. Staff interviews indicated that the resident was not safe to be outside alone, and that there was a lack of communication and documentation regarding his behaviors and risk status. Additionally, the facility failed to ensure that staff consistently signed out and carried pagers that would notify them of door alarms and resident call system activations. Several staff members did not have pagers during their shifts, and there were reports of insufficient pagers for all staff. This contributed to the lack of timely response to the door alarm when the resident exited the building. Facility policies required care plan updates and documentation of elopement risks and incidents, but these procedures were not followed in this case.
Failure to Honor Resident Rights and Dignity: Delayed Call Light Response and Unmet Preferences
Penalty
Summary
The facility failed to maintain residents' rights and dignity by not ensuring timely response to call lights, not keeping call lights within residents' reach, not providing meals and snacks according to residents' preferences, and not maintaining adequate lighting in a resident's room. Multiple residents reported or were observed to have call lights out of reach, resulting in them having to yell for assistance or wait extended periods, sometimes over 30 minutes or even an hour, before receiving help. In one instance, a resident was unable to access the call light and had to rely on shouting for staff, while another resident's family member reported that the call light was activated but not answered in a timely manner, leading to incontinence due to the delay. Residents also reported issues with meal service, including not receiving meals or snacks as ordered, receiving cold or incorrect food, and not having their dietary preferences honored despite repeated requests. One resident was documented as missing meals for two days, with no record of meal intake or snacks provided on certain days, and experienced significant weight loss during their stay. Another resident repeatedly received food items they disliked or had specifically requested not to receive, such as white bread instead of wheat bread, or fish and zucchini despite these being listed as dislikes on their meal slip. Additionally, the facility did not ensure that environmental needs were met, as evidenced by a resident's request for a working light above their bed, which was found to be nonfunctional with exposed wires and no bulb. Staff interviews confirmed that call lights were not always left on until needs were met, and that residents sometimes received whatever food was being served rather than their stated preferences. Facility policies reviewed indicated requirements for timely meal service, honoring resident preferences, and maintaining dignity, but these were not consistently followed as observed and reported.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to immediately report allegations of sexual abuse to the Abuse Coordinator and did not timely notify the State Agency regarding a suspected abuse incident involving a resident with severe cognitive impairment and multiple medical conditions. The resident, who was dependent on staff for all activities of daily living, was observed by staff to have vaginal bleeding and swelling, and exhibited increased distress during perineal care. Staff notified the DON and the on-call provider, who recommended hospital evaluation, but did not clearly communicate suspicion of possible abuse to the facility administration at that time. The resident was transported to the hospital, where a rape test was ordered and the police were notified by hospital staff due to suspicion of sexual abuse. The facility administrator was not made aware of the potential abuse until the police arrived at the facility, having been contacted by the hospital. It was only after speaking with the resident's legal guardian and learning of the hospital's actions that the administrator recognized the need to initiate an internal investigation and report the incident to the State Agency. The delay in reporting resulted in a late start to the facility's investigation and a failure to promptly assess other residents for potential abuse. The State Agency was not notified of the allegation until the day after the incident, and the facility's own investigation and interviews with staff and residents were not initiated until after the administrator became aware of the situation from external sources.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posting of nursing staff information was accurate and updated as required. During a review of the BIPA (Benefits Improvement and Protection Act of 2000) forms, which the facility used for mandatory daily staffing postings, discrepancies were found between the posted information and the actual staffing schedules for several dates. For example, the number of Certified Nursing Assistants (CNAs) and nurses, as well as their total hours worked, did not match between the BIPA forms and the staffing schedules. These errors were present on multiple dates, and the posted information was not reflective of the actual staff present on those days. When questioned, the Nursing Home Administrator (NHA) initially stated that the postings should be correct, but upon further review, both the NHA and the Director of Nursing (DON) acknowledged that the BIPA forms did not accurately reflect the staffing. The DON identified that new staff were not properly coded, resulting in their absence from the posted staffing information. The facility's policy required that staffing information be posted in an accessible area for all staff and residents, but this requirement was not met due to the inaccuracies in the posted data.
Failure to Provide and Document ADL and Hygiene Care
Penalty
Summary
The facility failed to ensure the provision and documentation of Activities of Daily Living (ADL) and hygiene care for five residents. Concerns were raised about inadequate staffing and residents not receiving proper care, including showers and grooming. Observations and record reviews revealed that residents were often found in bed with unkempt appearances, and there was a lack of documentation for ADL care, including bathing and oral hygiene. Resident #701 was severely cognitively impaired and dependent on staff for ADLs. The resident was observed with an unkempt appearance and had received only one bed bath and no showers during February 2025. There was no documentation of oral care on several days, and no records indicated that the resident refused ADL care. Similarly, Resident #702, who was cognitively intact but required total assistance for ADLs, was observed in a disheveled state and had received only one bed bath with no oral care documented during the day or evening shifts. Resident #703, who was dependent on staff for all ADLs, was transferred to the hospital and did not return. A family member expressed concerns about insufficient bathing and hygiene care due to understaffing. Resident #704, severely cognitively impaired, was observed with an unclean appearance and had received only one bed bath with minimal oral care documented. Resident #705, who was also severely cognitively impaired, received one bed bath and limited oral care before passing away. The Director of Nursing confirmed the lack of documentation for ADL care and indicated that staff might not be documenting the care provided.
Deficient Call Light System in Short-Term Units
Penalty
Summary
The facility failed to ensure an operational call light system in the short-term units, specifically in the 100, 200, 300, and 400 hallways. Observations revealed the absence of a central call light monitoring screen and visual light indicators outside resident rooms. Interviews with staff, including RNs and CNAs, confirmed that the call light system had been non-functional for about a month, with the central monitoring screen broken and pagers either unavailable or delayed in notifying staff of resident needs. Staff interviews highlighted significant communication issues due to the lack of a functioning call light system. RN I mentioned that the facility relied on a pager system, but not all staff had access to pagers, and those who did experienced delays in notifications. CNA J and CNA K reported not having pagers and relied on frequent room checks to determine if residents needed assistance. CNA M, who had a pager, noted a delay in receiving notifications from other halls, with a demonstrated 10-minute delay in one instance. The facility's administration, including the Administrator and DON, acknowledged the issues with the call light system and the lack of pagers. They confirmed that pagers should be available for all CNAs, but an inspection of the pager drawer revealed none were available for the short-term unit. The Maintenance Director, new to the role, was unaware of the pager system's issues but mentioned that replacement pagers had been purchased but could not be programmed due to a faulty docking station. The facility's policy emphasized the importance of a functional call light system, but the current situation did not align with these guidelines.
Failure in Timely Nursing Assessment and Response
Penalty
Summary
The facility failed to ensure timely nursing assessment, response, and documentation for a change in condition for a resident, leading to a deficiency. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed to have a change in condition early in the morning. Despite being a full code, the resident was found unresponsive, and a code blue was called. The timeline of events indicates that the resident was observed to be congested, and upon returning to the room, the nurse found the resident with decreased response, leading to the initiation of CPR. The documentation and interviews reveal significant gaps in the response to the resident's change in condition. The nurse failed to document any assessments or interventions in the resident's electronic medical record (EMR) related to the change in condition and subsequent death. Interviews with staff indicated that the nurse was scattered and did not perform a thorough assessment or apply necessary interventions such as oxygen administration when the resident's SPO2 was low. The nurse also left the resident unattended at a critical time, and there was a delay in calling the code and initiating appropriate emergency measures. Further interviews with other staff members, including the LPN and CNA, corroborated the lack of timely and appropriate response. The LPN noted that the resident was blue and gurgling, and upon entering the room, they found the resident in distress. The CNA also reported that the resident was breathing noisily and rapidly, yet the nurse dismissed these concerns. The facility's Director of Nursing (DON) and Administrator confirmed concerns about the lack of timely interventions and the scattered nature of the nurse's responses, highlighting a failure in the facility's processes to ensure proper care and documentation.
Deficiencies in Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper maintenance and labeling of tube feeding equipment and supplies for several residents, leading to deficiencies in care. For Resident #90, observations revealed that the tube feeding pump was alarming, and the solution bottle and tubing lacked date and time labels. The total volume fed and water flush volumes were inaccurate, and the water flush bag appeared full despite the recorded flush volume. Additionally, the insertion site had dried crusty buildup, and an undated, discolored dressing was found, which was not ordered by a physician. The facility's Director of Nursing (DON) and Unit Manager (UM) acknowledged these issues but did not provide follow-up information before the survey concluded. Resident #35's tube feeding equipment was also improperly labeled, with the enteral nutrition formula and water bag not infusing as per the physician's orders. The resident had experienced weight loss, and the Registered Dietitian (RD) had recommended increased tube feeding and water, which was not accurately reflected in the equipment observed. The Assistant Director of Nursing confirmed that the tube feeding bottle and water should have had the correct information, indicating a lapse in adherence to updated orders. For Resident #34, the enteral feeding was not running, and the tubing was not dated or capped, leaving it open to air. The DON confirmed that the tubing should be capped and dated with a time. Similarly, Resident #53's tube feeding was observed to be infusing past the 24-hour limit, with the tubing not properly labeled. The DON acknowledged that the tube feeding should have been changed the previous day, highlighting a failure to adhere to the facility's policy of changing tube feeding every 24 hours.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure that residents received oxygen as ordered, leading to deficiencies in respiratory care for several residents. Resident #21 was observed with an empty oxygen tank, causing her to breathe heavily and seek assistance. Despite the resident's need for oxygen therapy, the staff did not promptly replace the empty tank, and the resident had to wait for the Assistant Director of Nursing (ADON) to provide a new one. This delay in care highlights a lack of proper monitoring and management of oxygen supplies. Resident #24, who had a tracheostomy and required continuous oxygen therapy at 8 liters per minute, was found to have her oxygen set at only 2 liters per minute. This discrepancy between the physician's orders and the actual oxygen delivery was not addressed by the nursing staff, as evidenced by the initialing of the Medication Administration Record and Treatment Administration Record (MAR/TAR) without verifying the correct oxygen settings. Additionally, the resident's trach supplies were not properly managed, with an open bottle of normal saline left undated, posing a risk of contamination. Resident #83 also experienced improper oxygen management, with her oxygen set at 4 liters per minute instead of the ordered 2 liters per minute. The resident had a history of respiratory infections and required careful monitoring of her trach secretions, which were observed to be thick and discolored. The suction canister in her room was nearly full, indicating a lack of timely trach care. Similarly, Resident #30's oxygen was set at 5 liters per minute, contrary to the physician's order of 2 liters per minute. The resident's CPAP mask was not in use, and the nebulizer mask was improperly stored, further demonstrating inadequate respiratory care management by the facility.
Lack of Yearly Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that Licensed Nurses (RNs and LPNs) and Certified Nursing Assistants (CNAs) received yearly competency evaluations. This deficiency was identified during a survey when it was found that six out of seven staff members reviewed did not have current evaluations for 2023 or 2024. The Human Resources (HR) Personnel confirmed the absence of these evaluations, noting that the only available evaluations were from the staff's orientation period. The HR Personnel also indicated that the previous administration had not completed the required yearly evaluations. During an interview, the Director of Nursing (DON) acknowledged the lack of yearly evaluations and stated that she became aware of this issue upon starting her role two months prior. The DON reported that evaluations were in progress with the Unit Managers, who work closely with the nursing staff. The absence of these evaluations suggests that the nursing staff may not have received the necessary training and skills updates to adequately care for the residents, which could impact the residents' well-being.
Inaccurate and Incomplete Nurse Staffing Records
Penalty
Summary
The facility failed to post accurate and updated nurse staffing records, as required by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). During an interview with the Scheduling Coordinator (SC), it was observed that the nurse staffing posting for a specific day did not include registered nurse (RN) hours, which the SC attributed to a printing error. Additionally, the SC admitted that the postings were supposed to be updated daily, including weekends, but there were inconsistencies in the records. The binder containing retained nursing staffing posted hours was incomplete, with multiple days missing and conflicting data for the same day, indicating a lack of proper record-keeping. Further review of the staffing schedules compared to the BIPA documents revealed discrepancies in the number of certified nursing assistants (CNAs) and licensed practical nurses (LPNs) listed. For instance, on one day, the schedule indicated 16 CNAs, but the daily staffing record showed only 13. Similarly, another day's schedule listed 18 CNAs, but the BIPA document only recorded 14. These inconsistencies were confirmed by the SC, who was unable to determine which postings were accurate. The facility's failure to maintain accurate and complete nurse staffing records potentially affected all residents, their representatives, and visitors, as they were unable to determine the nursing staff on duty.
Medication Storage and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple medication carts, leading to several deficiencies. During observations, surveyors found loose tablets in a medication cart, which were not properly disposed of, and multiple instances of opened multi-dose medications that were not dated. This included Fluticasone Propionate nasal spray, Valproic acid, and Morphine, all of which were found without an open date, potentially affecting their efficacy and safety. Additionally, Budesonide nebulizer vials were found undated and without resident identification, further indicating lapses in medication management. The facility's narcotic reconciliation process was also found to be deficient. Observations revealed discrepancies in the narcotic count sheets, including scribbled numbers and incorrect documentation of dates and signatures. For instance, Nurse O was observed signing the narcotic count sheet for a date when they were not present in the building, and there were instances where the narcotic count was not accurately reconciled, leading to potential errors in narcotic management. The Director of Nursing acknowledged these issues and noted that spot checks were conducted weekly, but the deficiencies persisted. The facility's policies on medication storage and labeling were not adhered to, as evidenced by the lack of date-opened stickers on medications and improper narcotic count documentation. The pharmacy services policy required nurses to record the date opened and expiration date on medications, but this was not consistently followed. The Director of Nursing admitted that there was a previous nurse education session on proper documentation, but the issues remained unresolved, highlighting a systemic problem in medication management and reconciliation within the facility.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plan interventions for two residents, resulting in potential unmet care needs. Resident #74, an elderly male with severe cognitive impairment and multiple medical diagnoses, was observed with a urinary catheter and tubing on the floor, which was not addressed in his care plan. Despite having a history of recurrent urinary tract infections (UTIs), there was no documented order for the catheter beyond a one-time insertion, and no care plan for catheter care was in place. The facility's interdisciplinary team did not ensure the care plan was updated to include catheter monitoring and care. Resident #75, a male with multiple medical conditions including dementia and anxiety, was prescribed Clonazepam without documented risk versus benefits or medication education for the resident or responsible party. The facility's policy requires documentation of the specific condition diagnosed by a physician and education on the risks and benefits of psychotropic drug use. However, the care plan for Resident #75 did not include interventions to monitor the effects of Clonazepam, and there was no evidence of consent or education provided. The deficiencies highlight a lack of adherence to the facility's policies on comprehensive care planning and psychotropic drug use. The care plans for both residents were not updated to reflect their current medical needs and treatments, potentially leading to unmet care needs and prolonged illness or injury. The facility's failure to ensure proper documentation and monitoring of medical interventions and medications contributed to these deficiencies.
Failure to Follow Physician's Orders for Metoprolol Administration
Penalty
Summary
The facility failed to adhere to physician's orders for monitoring blood pressure and heart rate parameters when administering Metoprolol to Resident #34. The resident, who was admitted with diagnoses including stroke, diabetes, and essential hypertension, had an order for Metoprolol Tartrate to be administered via PEG-Tube every morning and at bedtime, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. However, the Medication Administration Record (MAR) for October, November, and December 2024 showed repeated instances where the medication was administered despite blood pressure readings that should have prompted the medication to be held. In October 2024, there were 23 days with repeated blood pressure and pulse readings documented for both morning and bedtime administrations, with three instances where the medication was given despite blood pressure readings being outside the prescribed parameters. Similarly, in November 2024, there were 23 days with repeated readings and two days with transcription errors in blood pressure documentation. In December 2024, the MAR continued to show repeated blood pressure and pulse readings for consecutive administrations. An interview with the Director of Nursing (DON) revealed that the facility's practice allowed nurses to document the last recorded blood pressure and pulse, rather than taking new readings at the time of medication administration. The DON acknowledged the unlikelihood of consecutive identical blood pressure readings and confirmed that the facility's policy required nurses to obtain and record vital signs at the time of administration when parameters were specified. The facility's policy on medication administration emphasized the importance of holding medication for vital signs outside the physician's prescribed parameters.
Deficiencies in Nail and Denture Care
Penalty
Summary
The facility failed to provide adequate assistance with denture care and nail care for two residents, resulting in potential risks for embarrassment, skin injury, and infection. Resident #11, who had a history of stroke, dementia, and other conditions, was observed with long, jagged fingernails and old nail polish. Despite the resident's indication that the nails were too long and consent to have them trimmed, the facility did not have interventions in place to address refusals of nail care. The Unit Manager acknowledged the need for nail care during showers, but the Activities Director reported that the department had not been doing nails, leaving the responsibility to families. Resident #51, who was independent in activities of daily living, was found with a denture cup containing debris and cream-colored dots, suggesting food debris. The Infection Control Nurse confirmed the need for the cup to be cleaned. The facility's policies on activities of daily living and nail care were not adequately followed, as routine cleaning and inspection of nails and denture care were not provided as needed. The Director of Nursing acknowledged the lack of interventions for refusals in the care plans, indicating an area of improvement needed in the facility's care practices.
Deficiencies in Hospice Coordination and Wound Care Management
Penalty
Summary
The facility failed to coordinate and collaborate hospice services for a resident, ensuring comprehensive care was not provided. The resident, who had a terminal prognosis and was receiving hospice care, had a care plan that included hospice interventions. However, the facility did not maintain up-to-date hospice documentation, as the last hospice note in the electronic medical record was from a month prior. Interviews with social services staff revealed that the hospice book, which should have contained notes on services and visits, only had outdated care plans and documents. Another deficiency was identified in the facility's failure to complete timely assessment and monitoring of skin conditions and change bandages and sheets for a resident. This resident, who had recently been admitted after a septic episode, was observed with saturated bandages and soiled sheets. The resident's husband expressed concerns about the lack of dressing changes and pain management. The facility's policy required licensed nurses to notify physicians for treatment orders in the absence of such orders, but this was not adhered to, as evidenced by the lack of orders for the resident's coccyx dressings. The facility's Director of Nursing and Assistant Director of Nursing were involved in reviewing the resident's condition, but discrepancies in documentation and care were evident. The resident's medical records indicated multiple serious diagnoses, including gangrene and sepsis, yet the facility did not adequately address the resident's wound care needs. The facility's policy on wound treatment management was not followed, as dressings were not changed despite being visibly soiled, and there was no documentation of a comprehensive skin assessment upon admission.
Failure to Prevent Decline in Range of Motion and Development of Contractures
Penalty
Summary
The facility failed to ensure a thorough initial therapy assessment and prevent a reduction in range of motion and the development of contractures for a resident with limited range of motion. The resident, who had been at the facility for one year, reported that therapy had not attempted to stand him up and that he was previously able to walk with a cane but could no longer do so. Upon review of the resident's medical records, it was found that his baseline range of motion was not comprehensively assessed upon admission, with many sections marked as not applicable, and contractures were not noted. The resident's progress notes indicated a decline in functional abilities and the development of contractures, which were not present upon admission. The therapy director acknowledged that the resident's range of motion had declined since admission, and new contractures had developed. The resident's therapy discharge summaries and plans indicated a decline in overall mobility and the development of contractures, which were not initially assessed or documented upon admission. Interviews with the therapy director and physical therapist revealed that the resident was not placed on a restorative program to maintain his level of functioning, despite a decline in range of motion and the development of contractures. The facility's policy on range of motion stated that residents should not experience a reduction in range of motion and that assessments should be conducted on admission, quarterly, and upon significant changes. However, the facility failed to adhere to this policy, resulting in the resident's decline in mobility and the development of contractures.
Deficiencies in Urinary Catheter Management and UTI Care
Penalty
Summary
The facility failed to provide necessary management and care of indwelling urinary catheters for three residents, leading to potential complications. Resident #24 was observed with a Foley catheter bag improperly placed on the floor, and the catheter tubing showed signs of thick yellow urine with sediment and biofilm. There was no physician order or documentation for the presence of the catheter in the resident's medical records, and the care plan did not mention the catheter until three weeks after its insertion. The Assistant Director of Nursing confirmed the absence of a physician's order and acknowledged the improper placement of the catheter bag. Resident #73 had a history of recurrent urinary tract infections (UTIs) and was observed with a Foley catheter. The resident's urine culture identified two organisms, but no antibiotic sensitivity was provided. The facility's Infection Control Practitioner noted the high UTI rate and the lack of antibiotic sensitivity in lab results, which hindered appropriate treatment. The resident had a chronic sacral wound with osteomyelitis and had been on long-term antibiotic therapy, complicating the management of recurrent UTIs. Resident #74 was observed with a urinary catheter and tubing on the floor, and the resident was unaware of the catheter's purpose. The laboratory results for the resident's urine identified multiple pathogens, but there was no recommendation for colonized organisms. The facility's records lacked a physician order for the catheter beyond a one-time order, and there was no care plan for catheter care. The Regional Clinical Consultant acknowledged the absence of a proper catheter care plan and the need for a physician order if the catheter was to remain in place.
Failure to Respond to Pharmacy Recommendations for Unnecessary Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations for two residents regarding unnecessary medications. For one resident, the facility did not respond to three out of four pharmacy recommendations within the lookback period. These recommendations included conducting specific lab tests and correcting the administration route of an oral antibiotic. The facility's Director of Nursing (DON) acknowledged that the recommendations were not accessible in the medical record prior to October 2024 and had to contact the pharmacy to obtain them. The facility's policy requires that the attending physician document any action taken in response to pharmacy recommendations, but this was not done. For another resident, the facility did not document or sign off on pharmacy recommendations for discontinuing certain medications and monitoring orders. The recommendations were not accessible in the medical record, and the facility had to request them from the pharmacy. The DON confirmed that before October 2024, the facility did not have copies of the pharmacy recommendations. This lack of documentation and response to pharmacy recommendations indicates a failure to adhere to the facility's policy on addressing medication regimen review irregularities.
Failure to Provide Risk-Benefit Analysis for Psychotropic Medication
Penalty
Summary
The facility failed to provide risk versus benefits analysis and medication education to a resident or their responsible party before administering a benzodiazepine medication. This resulted in the resident being given clonazepam without appropriate documentation of the risks and benefits being explained. The resident, a cognitively impaired male with multiple medical diagnoses including anxiety and depression, was observed in his room and was noted to be making repetitive throat clearing noises. Despite the initiation of clonazepam for anxiety, there was no record of risk versus benefits analysis or education provided to the resident or their legal guardian. The facility's policy on the use of psychotropic drugs requires documentation of the specific condition diagnosed by a physician and education on the risks and benefits of psychotropic drug use. However, interviews and record reviews revealed that the necessary documentation and education were not completed. The social services department was responsible for initiating the psychotropic consents and risk forms, but these were not found in the resident's medical record. Attempts to contact the resident's wife for consent were made only after the surveyor's inquiry, indicating a lapse in the facility's protocol for medication administration.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident during a lunch meal, which resulted in the resident consuming food they did not like. On December 3, 2024, Resident #22 was observed sitting at a dining table with a meal that included mashed potatoes and gravy, and carrots, despite their meal ticket indicating dislikes for these items. When asked, the resident expressed that they did not like mashed potatoes but would eat what was available. This incident occurred during a dining task review involving fifteen residents. Resident #22, who was admitted on September 8, 2022, has diagnoses including Dementia, Mood Disturbance, and Anxiety, and requires extensive assistance with Activities of Daily Living (ADLs) due to severely impaired cognition. A review of the resident's electronic medical record showed an intervention to obtain and honor food preferences within dietary parameters, initiated on September 26, 2023. However, discrepancies were found in the meal tickets, with dislikes listed alongside alerts for gravy on all meats. The Registered Dietician acknowledged the issue and noted that speech therapy often adds alerts to meal tickets, indicating a lack of coordination in updating the resident's preferences.
Improper Medication Administration and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure proper medication administration and cleanliness of reusable medical equipment for a resident. During a medication administration task, a nurse prepared medications for a resident and needed to cut two larger pills. The nurse used a pill cutter that was soiled with a moderate amount of white residue. After cutting the pills, the nurse placed them into a medication cup using bare hands, which is against the facility's medication administration policy. The nurse then administered the medications to the resident. The Infection Control Nurse confirmed that oral medications should not be touched with bare hands and that soiled pill cutters should be cleaned.
Failure to Obtain Lab Results Before Antibiotic Use
Penalty
Summary
The facility failed to obtain laboratory results for the use of antibiotics prior to starting antibiotic therapy for two residents, potentially affecting all residents. Resident #6 was administered Cephalexin for a possible urinary tract infection (UTI) without any laboratory results or symptoms noted by the facility. The Infection Control Nurse was unable to locate any risk vs. benefit analysis or laboratory results in the resident's chart, despite the facility's policy requiring such evaluations. Resident #73 had a urine culture that identified two organisms, but no antibiotic sensitivity was provided to determine the most appropriate antibiotic. The resident was prescribed Cefdinir without sensitivity results, and had a history of recurrent UTIs and long-term antibiotic therapy. The facility's Infection Control Practitioner noted a high UTI rate and multiple residents receiving antibiotics without urine testing, often citing risk vs. benefit or hospice as justification. The facility's infection surveillance data showed a significant number of residents receiving antibiotics for UTIs and skin/soft tissue infections, with many treated multiple times. The Corporate Clinical Nurse acknowledged the lack of antibiotic sensitivity testing and the large volume of antibiotics being used, but no specific actions had been identified to address these issues.
Failure to Implement Care Plan for Resident with Impaired Hepatic Status
Penalty
Summary
The facility failed to implement a care plan for a resident with impaired hepatic status, which was one of the three residents reviewed for care plans. The resident, who was alert and required assistance with activities of daily living, had a complex medical history including gangrene of fingers, diabetes, chronic obstructive pulmonary disease, heart failure, atrial fibrillation, anemia, alcoholic cirrhosis of the liver, chronic pancreatitis, and elevated liver transaminase levels. The resident was transferred to the hospital with a distended gallbladder, a large amount of ascites, and a small right-sided pleural effusion with compressive atelectasis. The care plan required monitoring and reporting increases in abdominal pain and girth, which were not documented by the facility. The facility's nursing notes and electronic medication administration records did not show any assessment or monitoring of the resident's abdominal girth or the location of pain for which pain medications were administered. This lack of documentation and monitoring was acknowledged by the nursing staff during interviews. The deficiency resulted in the resident being admitted to the ICU for evaluation and treatment of conditions including acute or chronic pancreatitis and liver cirrhosis. The facility's baseline care plan stated the need for developing and implementing a care plan that meets professional standards of quality care, which was not adhered to in this case.
Failure to Provide Mental Health Services Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with a long history of mental illness, including bipolar disorder, anxiety, attention deficit, and borderline personality disorder, received necessary mental health services during their stay. The resident, who had a known history of violence and harm to animals, was admitted to the facility and later discharged to the hospital following a major psychotic episode. The episode involved violent and aggressive behaviors towards staff, necessitating police intervention. Despite the resident's complex mental health needs, there was no documentation of any referrals for mental health services until the day of the resident's discharge to the hospital. Interviews and record reviews revealed that the facility did not contact the resident's previous mental health service provider, Central Michigan Health (CMH), upon admission or during the resident's stay. The Director of Social Services discontinued the resident's Haldol medication without titration and did not make a timely referral to mental health services. A referral to Behavioral Care Solutions was prepared but never sent, and the mental health nurse practitioner confirmed that they never received a referral. The facility's admissions policy stated that residents who can be adequately cared for by the facility should be admitted, yet the necessary mental health services were not provided, leading to the resident's hospitalization.
Failure to Implement Legionella Control Measures
Penalty
Summary
The facility failed to implement necessary infection prevention and control measures after a resident tested positive for Legionella. Despite being notified by the Local Health Department, the facility did not initiate remediation measures, complete and submit a Legionella Environmental Assessment Form (LEAF) in a timely manner, or provide representative environmental water samples for retesting. This inaction occurred even though the facility's water had previously tested positive for Legionella on several occasions. The facility also did not collect urine antigen and sputum samples for residents exhibiting respiratory or pneumonia symptoms to test for Legionella. This failure affected 27 of 59 sampled residents who showed signs of respiratory illness. The Health Department had repeatedly requested these actions, but the facility did not comply, placing residents, staff, and visitors at risk of exposure to Legionellosis. Additionally, the facility did not implement recommended infection control practices, such as installing 0.2 micron filters on sinks and shower heads, restricting the use of certain water sources, and notifying residents and families about the potential exposure. The facility's lack of cooperation with the Health Department's investigation and failure to provide requested information hindered the assessment of Legionella exposure risk within the facility.
Removal Plan
- The Administrator provided education to the Maintenance Director after a positive Legionella water sample.
- The Director of Nursing provided education to the Infection Preventionist on checking for and documenting signs and symptoms of Legionella on the facility's Infection Line Listing and performing urine antigen and sputum cultures as indicated.
- The Infection Preventionist/Designee began education to the staff nurses on documenting signs and symptoms of Legionella and to notify the hospital on the need for testing urine antigen and sputum cultures for those residents transferred to the hospital with signs and symptoms of Legionella.
- The Medical Director was notified.
- The Director of Nursing/Designee completed chart audits for all residents to assess for signs and symptoms of Legionella. Any resident with signs and symptoms was tested via urine antigen and sputum culture if able.
- The facility held a QAPI meeting and reviewed the policies: Water Management Program, Infection Surveillance and the Infection Prevention and Control Program. The Abatement Plan was reviewed at QAPI.
- The facility alleged compliance.
Failure to Document and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to implement policies and procedures to ensure a comprehensive and accurate assessment and documentation for a resident, resulting in a lack of accurate, complete, and concise documentation and nursing assessment for a change in condition. The resident, who was admitted with multiple diagnoses including a hip fracture, diabetes, and heart disease, was transferred to the hospital after experiencing a significant decline in health. The resident's family member reported that the resident had difficulty breathing and low oxygen saturation levels, but the facility staff's response was inadequate, as they only put the resident to bed without further intervention. The resident's medical records revealed inconsistencies in the documentation of oxygen therapy and blood glucose monitoring. Despite having an order for continuous oxygen therapy, the records indicated that the resident was not receiving supplemental oxygen for several days. Additionally, the resident's blood glucose levels were monitored inconsistently, and there was a lack of documentation regarding the administration of glucagon and other interventions for low blood sugar. The facility's Director of Nursing was unable to provide explanations for these discrepancies during an interview. The facility's policies on notification of changes and oxygen administration were not followed, as evidenced by the lack of comprehensive respiratory assessments and failure to notify the resident's physician of significant changes in condition. The resident was eventually transferred to the hospital, where they were diagnosed with Legionella pneumonia, COVID-19, and influenza, leading to severe respiratory issues and the need for hospice care. The facility's failure to document and respond appropriately to the resident's symptoms and changes in condition contributed to the deficiency.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered timely and as ordered for a resident, leading to doses being given too close together and too far apart. This deficiency was identified for a resident who was admitted with multiple diagnoses, including hydrocephalus, bipolar disorder, rheumatoid arthritis, anxiety, chronic pain syndrome, and a history of pulmonary embolism. The resident reported receiving Gabapentin, an anticonvulsant, at incorrect times, specifically noting that on one occasion, doses were administered in the morning and then again shortly before noon, despite the medication being prescribed to be taken every eight hours. A review of the Medication Administration Record (MAR) confirmed that the Gabapentin was not administered as ordered, with doses given at irregular intervals. The Director of Nursing acknowledged the issue, noting that the medication should not have been administered so closely together and that the resident sometimes refused evening doses. The facility's policy on medication administration requires that medications be given as ordered by the physician, which was not adhered to in this case.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident, leading to a fall and a serious injury. The resident, an elderly female with multiple health issues including chronic respiratory failure, congestive heart failure, and muscle weakness, required assistance for mobility and transfers. Her care plan specified the need for assistance from 1-2 people for bed mobility and transfers with a mechanical lift. Despite these requirements, the resident was found on the floor with a serious laceration on her right knee, indicating a lack of supervision and assistance. The incident report revealed that the resident was found on her right side next to the bed, with no staff witnessing the fall. The report lacked details on who provided care or when care was last given, and the bed height was noted as a predisposing environmental factor. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the fall was not investigated, and the standard of care, which requires care every two hours, was not met. The only staff member still employed at the facility recalled that the resident's bed was in a raised position, which may have contributed to the fall. Following the fall, the resident was hospitalized with a large laceration on her right knee, which required significant medical intervention. The hospital records indicated that the resident experienced confusion, an abnormal heartbeat, and significant electrolyte imbalance. Despite medical efforts, the resident's condition deteriorated, and she passed away. The lack of adequate supervision and failure to follow the care plan contributed to the resident's fall and subsequent hospitalization.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to ensure an environment free of abuse for four residents, resulting in incidents of verbal and physical abuse by another resident. The incidents involved a resident with a history of cognitive impairment and behavioral issues, including predatory sexual tendencies and aggression. Despite having care plans in place to manage these behaviors, the facility did not effectively prevent the resident from engaging in abusive actions towards other residents. The incidents spanned over a period of nearly two years, with multiple altercations involving different residents. These included verbal threats, inappropriate touching, and physical aggression. In each case, the facility's investigations concluded that abuse was unsubstantiated, and no law enforcement or psychiatric evaluations were conducted for the resident exhibiting abusive behavior. The facility's documentation and care plans acknowledged the resident's behavioral issues, yet the measures taken were insufficient to prevent further incidents. The facility's policy on resident rights emphasized the responsibility to protect residents from abuse and to screen prospective residents for the facility's capability to provide necessary care. However, the repeated incidents indicate a failure to implement effective supervision and intervention strategies to safeguard residents from harm. The resident in question was eventually discharged to an AFC home after the last reported incident.
Resident's Rights Violated Due to Medication Delay
Penalty
Summary
The facility failed to uphold the resident's right to dignity and self-determination, as evidenced by the case of a resident who experienced significant distress due to the unavailability of her prescribed antianxiety medication, alprazolam. The resident, who was admitted with a diagnosis of adjustment disorder with anxiety, among other conditions, did not receive her medication for approximately 24 hours after admission. This delay was attributed to ongoing issues with the facility's pharmacy in obtaining controlled substance prescriptions in a timely manner. Despite the resident's repeated requests and visible distress, the facility did not provide any documented comfort measures or alternative interventions to alleviate her anxiety during this period. The Director of Nursing (DON) acknowledged the pharmacy-related issues and the resident's distress but did not instruct staff to stay with the resident or provide any documented support. The resident expressed feelings of being in a "different world" and engaging in "crazy things" when deprived of her medication, highlighting the emotional and psychological impact of the deficiency. The lack of timely medication administration and absence of supportive measures resulted in the resident experiencing frustration and mental anguish, thereby violating her rights to dignity and self-determination.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in chronic wound contamination and worsening of pressure ulcers. The resident, a male with chronic respiratory failure, cerebral infarction, and dependence on a respirator, was observed with unstageable pressure ulcers on the sacral region, right trochanter, and left medial calf. Despite having a care plan that included interventions for bed mobility, toileting, and transfers, the resident was found with pressure ulcers that were not properly relieved, and his wounds were frequently contaminated with urine and feces. Observations revealed that the resident was often positioned in a way that did not relieve pressure on his ulcers, with devices such as wedge cushions and heel floating devices not being used correctly. The resident's sacral wound was frequently soiled, and staff indicated that his tube feeding caused constant stooling, while the absence of a catheter led to urine contamination. Despite the presence of a specialty mattress, the facility did not ensure consistent use of pressure-relieving devices, and the care plan lacked specific instructions for pressure relief frequency and device utilization. Interviews with the Director of Nursing and other staff confirmed that there was a lack of proper training and care planning for pressure ulcer management. The facility's documentation showed inconsistent wound measurements and treatment changes, with some wounds worsening over time. The facility did not adequately address the concerns of pressure relief and incontinence care, and there was no evidence of communication with the resident's guardian regarding the chronic contamination of the sacral wound.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to maintain proper infection control prevention during tracheostomy suctioning for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including chronic respiratory failure requiring a tracheostomy, was observed needing suctioning. During the procedure, an LPN used unsterile gloves and did not adhere to sterile technique, despite the facility's policy requiring sterile gloves for tracheal suctioning. The LPN was unaware of the requirement for sterile gloves and continued the procedure without them. The facility's Infection Control and Nurse Educator confirmed that the facility's policy mandates sterile technique for tracheostomy suctioning, and the Director of Nursing acknowledged the concern. The discrepancy between the facility's policy and the vendor's checklist, which incorrectly indicated the use of clean gloves, was noted. The facility had previously conducted an in-service training on tracheostomy care, which emphasized the use of sterile technique, but this was not followed during the observed procedure.
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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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