Medilodge Of West Bloomfield
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bloomfield, Michigan.
- Location
- 6950 Farmington Rd, West Bloomfield, Michigan 48322
- CMS Provider Number
- 235487
- Inspections on file
- 33
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Medilodge Of West Bloomfield during CMS and state inspections, most recent first.
Surveyors found that an LPN administered medications to multiple residents without performing required hand hygiene before each administration, contrary to facility policy. In addition, during a COVID outbreak affecting residents and staff, the Infection Preventionist’s respiratory surveillance line list was incomplete and did not clearly identify COVID as the pathogen, with missing collection dates, unspecified test types, absent symptom onset and symptom documentation, and no recorded resolution dates, and the infection map for that period did not indicate which residents had COVID, despite policy requiring thorough surveillance documentation.
The facility failed to ensure residents were treated with dignity and respect, particularly during the night shift. Two residents who were cognitively intact reported long delays in call light responses, difficulty obtaining toileting and brief changes overnight, and situations where staff acknowledged requests for bathroom assistance but did not provide timely care, resulting in residents using briefs instead of being toileted. A family member reported that CNAs did not assist a resident when the call light was used at night and that nurses administered nighttime medications very late, and also stated that grievance forms were not provided for nursing concerns and that the social worker did not follow up on issues. Resident council minutes over several months documented repeated complaints about rude and unprofessional behavior by nursing, aide, and cleaning staff, issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing them about incontinence. In a group interview, multiple residents stated that some aides and nurses did not treat them with dignity or show genuine care, while the DON reported being unaware of these dignity concerns.
The facility failed to maintain a clean, safe, and homelike environment in shared pantry and shower areas. Surveyors observed a leaking ice machine with black, mold-like substance on the pantry floor tiles and water-damaged cabinetry with similar black growth under a sink, which the maintenance supervisor acknowledged without prior cleaning or recognition of new damage. In shower areas, a bariatric shower chair had torn vinyl exposing foam, and a C/D unit shower room contained significantly pitched tile flooring, a torn and heavily stained shower curtain, heavy dark debris buildup on wall and floor tiles, chipped wall tiles, and missing corner caps exposing sharp metal and plastic edges. The DON stated they were previously unaware of these environmental conditions, despite facility policy requiring housekeeping and maintenance to maintain a sanitary, orderly, and comfortable environment.
A resident was sent to the hospital for vomiting and returned with antibiotic orders for a UTI, after which the facility documented a suspected healthcare-associated UTI and initiated two courses of antibiotics. The McGeer infection surveillance checklist for this resident was not completed, and a spreadsheet later indicated the resident did not meet McGeer criteria, yet antibiotics were continued based on the hospital diagnosis and a physician’s verbal preference, without documentation of that discussion. The Infection Control RN reported not reassessing residents after antibiotics were ordered and was unsure if physicians reassessed the need, despite facility policy requiring monitoring of response to antibiotics and review of outside antibiotic orders for appropriateness.
A resident with severe cognitive impairment and a documented full code status was found unresponsive by an LPN, who observed no vital signs and reported the resident as having passed. Believing the resident to be a DNR based on incorrect verbal information, staff did not initiate CPR or other life-saving measures, and an RN pronounced the resident deceased upon arrival. Only after another LPN checked the electronic record and discovered the resident was full code did the RN initiate the code protocol and start CPR. Interviews showed the initial LPN did not know the resident’s or any assigned residents’ code status or where this information was documented, despite facility policy requiring advance directive decisions to be documented and communicated to care staff.
A resident discharged back to the community with Medicaid-MI as the payor source experienced a delay in the facility’s notification to the state agency to switch coverage from nursing home level Medicaid to community level Medicaid. The business office, which is responsible for this task, did not submit the request until several weeks after discharge, despite the usual practice of completing it on or shortly after the discharge date. The Regional Business Office Manager reported that the delay was related to the prior business office manager leaving, and facility policy indicated that social services are responsible for assisting residents with financial matters as part of medically related social services.
Surveyors found that an LPN removed and administered Ativan from a controlled medication drawer without verifying the count or documenting the dose at the time of removal, instead delaying controlled substance documentation until after completing multiple residents’ morning medications, contrary to facility policy. In a separate case, a resident with chronic diastolic heart failure, stage 3 CKD, and severe cognitive impairment experienced a change in condition with lethargy and low BP; although the provider ordered STAT labs and IV hydration with 0.9% NS at 70 cc/hr for one liter and Q6H vitals, the IV order was transcribed with an incorrect start date for the following day, resulting in a delay in carrying out the ordered treatment.
The facility failed to provide adequate medically-related social services for two residents with dementia and mood disorders following resident-to-resident altercations and documented behavioral concerns. One resident had severe cognitive impairment and repeated verbal and physical aggression toward a roommate, while another had severe cognitive impairment, depression, and anxiety with episodes of yelling, verbal aggression, and distress over loss of autonomy. Social service assessments for both residents were incomplete, missing key information on mood, behavior, triggers, calming strategies, and psychoactive medication review, and required quarterly assessments were not completed. There was no documented social services follow-up after alleged physical and verbal assault, subsequent roommate conflicts, or psych notes describing significant psychosocial distress, despite facility policy requiring initial and quarterly assessments, identification of psychosocial needs, and ongoing monitoring.
A resident with a seizure disorder and severe cognitive impairment had an order for Valproic Acid via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. On the day in question, the morning dose was not actually given until 12:44 PM, far outside the allowed administration window, and the evening dose was not administered at all, despite MAR entries indicating it had been given. Nursing notes documented two seizures in the early morning hours following these missed and delayed doses. The DON confirmed the significant delay of the morning dose and the omission of the evening dose, in contrast to facility policy requiring medications to be given per physician orders and identifying time of administration and omission as medication error factors.
A resident with severe cognitive impairment and a history of multiple falls was not consistently provided with the one-on-one supervision required by their care plan. Despite repeated documentation of the resident's restlessness, impulsivity, and need for close monitoring, the facility removed the one-on-one sitter, leading to several falls with injuries. Facility administration acknowledged the inability to maintain the required supervision and failed to implement an adequate alternative plan, resulting in repeated incidents and harm.
A resident with severe cognitive impairment alleged being pushed from her wheelchair by staff and was subsequently hospitalized. Although the allegation was communicated to facility leadership and APS was notified by the hospital, the facility did not report the incident to the State Agency as required by regulation and facility policy, with the Administrator stating they believed the incident did not occur.
A resident with severe malnutrition, dysphagia, and recent amputation experienced a rapid weight loss of over 15 pounds within four weeks due to the facility's failure to consistently monitor nutritional status, obtain required weekly weights, and implement or adjust interventions despite ongoing poor intake and documented feeding difficulties. The resident's significant weight loss was not identified or addressed by the Registered Dietician until after transfer to the hospital for extreme weakness and refusal of food and fluids.
A facility did not conduct a comprehensive investigation after a resident alleged sexual abuse. The investigation was limited to interviews with the resident's responsible party and two male staff, omitting interviews with other staff present at the time, the nurse who documented the initial report, and other residents. The Administrator/Abuse Coordinator was unaware of an earlier report by the resident, and the investigation did not follow facility policy requiring statements from all relevant witnesses.
A resident with severe cognitive impairment and mobility deficits fell in the shower after a CNA attempted a solo transfer, despite the resident's request for assistance. The fall was not documented or assessed by staff at the time, and management, physician, and responsible party were not promptly notified. The incident was only reported later by the resident, and no timely investigation or complete post-fall assessment was conducted, contrary to facility policy.
A resident with multiple serious conditions experienced a decline, prompting a physician to order STAT CMP and CBCD labs. The facility did not obtain these STAT labs as ordered, with staff stating their contracted lab did not provide STAT services on the needed day, despite the contract allowing for such services. The resident's condition worsened, and the labs were not completed prior to the resident's transfer out.
A resident reported confusion and believed a man had been in her room, later alleging sexual abuse to hospital staff. The facility's investigation was limited to interviews with the resident's responsible party and two male staff, omitting interviews with other relevant staff and residents, and the Abuse Coordinator was unaware of the initial report. This did not meet the facility's policy for a thorough abuse investigation.
A facility failed to maintain an effective infection control program, as evidenced by mishandling a MRSA case. A resident with a positive MRSA culture reported inadequate room cleaning and lack of protective equipment use by staff. The facility lacked infection control data for several months, and the DON was unaware of the MRSA case. The facility's policy requires ongoing infection monitoring, which was not followed.
The facility failed to maintain the hot water supply for 82 residents due to both boilers failing and not undergoing required CSD-1 inspections. The Maintenance Director confirmed the lack of hot water and revealed that the necessary maintenance and inspection were delayed, with no action taken by the corporate office. The facility's preventive maintenance policy was not followed, resulting in non-compliance with the CSD-1 code.
A resident with diabetes developed a scalp blister, initially dismissed by the physician as common. The resident's dermatologist diagnosed it as MRSA, but the physician failed to document the diagnosis or treatment in the records. Despite orders for antibiotics and precautions, the physician's notes did not reflect the MRSA diagnosis, indicating a lack of thorough documentation and follow-up.
A resident in a facility was not provided adequate assistance with activities of daily living, including regular bathing and transfers. The resident was left waiting for two hours to be transferred to a wheelchair, and reported rarely receiving showers due to staff reluctance. The facility's documentation showed only two showers since admission, with no refusals documented, despite the requirement for twice-weekly bathing offers.
A facility failed to identify, monitor, and assess a resident's skin impairment, leading to a missed MRSA diagnosis. Despite the resident's consultation with a dermatologist and subsequent MRSA diagnosis, the facility did not document the skin condition or follow up on the diagnosis. The attending physician and nursing staff provided conflicting information, and the Director of Nursing was unaware of the MRSA diagnosis, indicating a significant deficiency in care and monitoring processes.
The facility failed to return residents' clothing in a timely manner, as reported by several residents during a council meeting. Missing items included shirts and pants, with grievances documented in past meetings. Staff interviews revealed that the issue often stemmed from unlabeled clothing bags, complicating the return process. The Administrator acknowledged the problem, noting some residents' reluctance to label clothing.
The facility failed to ensure safe medication storage, with loose, unidentifiable pills found in a medication cart and a refrigerator storing insulin lacking a thermometer and temperature logs. An LPN acknowledged these issues, and the DON was informed, recognizing the need for proper storage and temperature monitoring.
The facility failed to maintain clean storage of linens and resident clothing in the laundry room, resulting in contamination with dust and dryer lint. Two linen carts with clean laundry were found covered in thick white debris, and the facility lacked a clean laundry storage policy. Housekeeping managers confirmed the unhygienic conditions.
A resident with Chronic Obstructive Pulmonary Disease and Adjustment Disorder was verbally threatened by a CNA at the nurse's station. The CNA used inappropriate and threatening language, which was corroborated by witnesses. The facility terminated the CNA and re-educated staff on abuse and neglect policies.
Inadequate Hand Hygiene and Incomplete Infection Surveillance During COVID Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement infection control standards during medication administration and to maintain an effective infection control surveillance program. During a medication pass, an LPN was observed administering medications to four residents, including residents 9 and 65, without performing hand hygiene before each medication administration for each resident. This practice was inconsistent with the facility’s Medication Administration policy, which requires staff to wash hands prior to administering medications and to follow facility hand hygiene protocols. In an interview, the DON confirmed that nurses are expected to perform hand hygiene before and after each medication administration for each resident. The facility also failed to maintain complete and accurate infection surveillance documentation during a COVID outbreak in October 2025 that affected 13 residents and six staff members. The Infection Control RN produced a Respiratory Surveillance Line List for that period and verbally confirmed that the listed individuals had tested positive for COVID, but the document itself did not specify COVID as the pathogen. The line list contained multiple blank or incomplete fields, including missing dates of specimen collection, unspecified test types marked only as “Other,” missing or “N/A” symptom onset dates, blank symptom documentation columns, and pathogen fields marked as “Other” without specifying the organism. The outbreak symptom resolution dates were blank for all names, and the October 2025 facility infection map did not indicate which residents had COVID. These practices did not align with the facility’s Infection Prevention and Control Program policy, which states that the Infection Preventionist leads surveillance activities and maintains documentation of incidents and findings.
Failure to Ensure Dignified, Respectful Care and Timely Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly regarding toileting, incontinence care, and staff interactions. One resident with diagnoses including difficulty in walking, polyneuropathy, and primary insomnia, and a BIMs score of 15 indicating no cognitive impairment, reported that night shift staff were not responsive to toileting needs. This resident stated they were only changed once during the night around 11:00 PM–12:00 AM and not again until approximately 6:30 AM, and that when they used the call light at night, a CNA would enter, ask what was needed, turn off the call light, and leave without providing toileting assistance until morning, resulting in the resident using the restroom in their brief. Another resident, also cognitively intact with a BIMs score of 15 and admitted with diagnoses including urinary tract infection and muscle disorder, reported that when they used the call light, it took staff so long to respond that they forgot what they had requested, and that it was difficult to get their brief changed on the night shift. A family member of one resident reported to the state agency that CNAs did not help the resident when the call light was used at night and that nurses did not administer nighttime medications until after 11:00 PM. The same family member stated they believed grievance forms were only available for missing items and not for nursing concerns, and also reported that the social worker did not follow up on requests. Resident council minutes over several months documented repeated concerns about staff attitudes and professionalism, including cleaning staff being rude, nurses and aides not being professional, ongoing issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing the resident about incontinence. In a confidential resident council interview with eight residents, multiple residents reported that some aides and nurses did not treat them with dignity, stating that staff did not “have a heart for the people” and did not actually care. The DON later reported being unaware of these dignity concerns. These findings occurred despite a facility policy on promoting and maintaining resident dignity that requires respectful communication and acting upon resident preferences.
Failure to Maintain Clean and Safe Pantry and Shower Environments
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment in multiple common-use areas, including the upper-level pantry and shower rooms. Surveyors observed an ice machine in the upper-level pantry leaking water onto the floor, with a black, mold-like substance present on the floor tiles. The cupboard under the pantry sink showed visible water damage and a black, mold-like substance on the bottom shelf. The Maintenance Supervisor stated they planned to get a new ice machine but did not explain why the mold-like substance on the floor had not been cleaned, and further reported he had repaired a leak under the sink about a year earlier but was not aware of any new leak or current water damage. In the upper-level shower room near the nurse's station, a bariatric shower chair was observed with torn vinyl on the seat, exposing foam and creating a surface that was no longer smooth and easily cleanable. In the C/D unit shower room, surveyors and the DON observed two shower stalls with significantly pitched tiled flooring, a torn and heavily stained white vinyl shower curtain, and a heavy buildup of dark, blackish debris along the wall and floor tiles inside the shower area. The tiled shower room walls had several chipped tiles, and plastic corner coverings were missing caps at the top, exposing sharp metal and plastic edges. The DON reported being unaware of these conditions prior to the observation. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment and that unresolved environmental concerns should be reported to the Administrator.
Failure to Monitor and Evaluate Antibiotic Use per Stewardship Program
Penalty
Summary
The deficiency involves the facility’s failure to monitor and evaluate antibiotic use for a resident in accordance with its antibiotic stewardship program. The Infection Control RN reported that the resident was sent to the hospital after vomiting yellow-green emesis and returned the same day with antibiotic orders for a urinary tract infection (UTI). The facility’s Infection Report Form listed an onset date of 10/13/25, a suspected healthcare-associated UTI, and documented orders for Keflex 500 mg every six hours from 10/14/25 to 10/18/25, followed by Macrobid 100 mg twice daily from 10/17/25 to 10/22/25. A McGeer Criteria for Infection Surveillance Checklist was started for this resident, but the criteria section was not completed. The Infection Control RN provided a spreadsheet indicating that the resident did not meet McGeer’s criteria for UTI, yet the antibiotics were continued. When asked why antibiotics were continued if criteria were not met, the RN stated they followed the hospital’s UTI diagnosis and that the attending physician wanted the antibiotics continued, but there was no documentation of this discussion. The Infection Control RN also stated they did not personally reassess residents after antibiotics were ordered and was unsure whether facility physicians assessed the relevance of the antibiotic therapy. These actions and omissions conflicted with the facility’s written Antibiotic Stewardship Program policy, which required monitoring response to antibiotics to determine ongoing need or adjustments, and review of antibiotic orders from consulting, specialty, or emergency providers for appropriateness.
Failure to Honor Full Code Status and Initiate Timely CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s full code advance directive by not initiating CPR or other life-saving measures when the resident was found unresponsive. The resident had diagnoses including Parkinson’s disease with dyskinesia and encephalopathy and had a BIMS score of 0/15, indicating severe cognitive impairment. When an LPN went to care for the resident at approximately 4:45 PM, the resident was observed unresponsive, with eyes open and fixed, mouth open, and no vital signs detected. The LPN then approached another LPN and reported that the resident had passed, inquired about the code status, and was told the resident was a DNR. Based on this information, no immediate resuscitative efforts were initiated. A supervising RN was called to pronounce death and, upon arrival, found the resident cool to the touch and not breathing, and pronounced the resident deceased. Shortly afterward, another LPN discovered in the resident’s profile that the resident was actually a full code. The RN then initiated the facility’s code protocol and started CPR only after learning of the correct code status. Interviews revealed that the LPN who first found the resident unresponsive did not know the resident’s code status, did not know where code status was documented, and did not know the code status of any assigned residents. The facility’s policy stated that decisions regarding treatment and advance directives were to be documented in the medical record and communicated to staff responsible for the resident’s care. The Administrator confirmed that, due to the unexpected death, the facility’s response to provide CPR and other life-saving measures was delayed.
Delay in Medicaid Status Change Following Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and timely discharge process for a resident whose Medicaid coverage needed to be transitioned from nursing home level to community level upon discharge. A complaint submitted to the State Agency alleged that the facility delayed notifying the Michigan Department of Health and Human Services that the resident had been discharged, which affected the resident’s ability to access community level Medicaid services. Record review showed the resident was admitted on an unspecified date and discharged back to the community on 8/1/25, with Medicaid-MI as the payor source at the time of discharge. During an interview, the Regional Business Office Manager explained that the facility business office is responsible for switching a resident’s Medicaid from nursing home level to community level, typically on the day of discharge, the next day, or by the end of that week. However, for this resident, the request to switch to community Medicaid was not submitted until 8/28/25, nearly four weeks after discharge. The Regional Business Office Manager attributed the delay to the prior business office manager leaving around that time. Review of the facility’s Social Services policy showed that the facility is responsible for providing medically related social services, including assisting residents with financial matters, to help them attain or maintain their highest practicable well-being.
Failure to Follow Controlled Substance Documentation Standards and Correctly Transcribe IV Hydration Order
Penalty
Summary
The deficiency involves failures in controlled substance administration and documentation, as well as incorrect transcription and implementation of a physician’s order. During a morning medication pass, an LPN prepared and administered Ativan 0.5 mg for a resident by removing one tablet from the locked controlled medication drawer and adding it to the resident’s other morning medications. The LPN did not verify the current Ativan count, did not document the dose removed on the controlled count sheet at the time of removal, and proceeded to prepare and administer medications for three additional residents without signing out the Ativan dose. When interviewed, the LPN stated they sign for controlled medications after completing all morning medication administrations and indicated that some nurses sign when removing the pill and others after finishing the medication pass. Facility policy on controlled substance administration and accountability requires that each dose administered be recorded, subtracted from the previous count, and the remaining amount documented. The deficiency also includes a failure to correctly transcribe and carry out a physician’s order for IV hydration for another resident with chronic diastolic heart failure, stage 3 chronic kidney disease, and severe cognitive impairment. A progress note documented that this resident was lethargic, difficult to arouse, with low blood pressure, but responsive to verbal stimuli and sternal rub, and with stable vital signs otherwise. The physician was notified and gave STAT orders for labs (CBC with diff, CMP, UA/urine culture), IV hydration with 0.9% normal saline at 70 cc/hr for one liter, and vital signs every six hours for 24 hours. However, the IV fluid order was transcribed in the medical record with an incorrect start date, setting the infusion to begin the following day instead of the same day, which created a delay in medical treatment. Attempts by surveyors to contact the nurse who transcribed the order were unsuccessful, and the regional nurse consultant could not explain why the order was not transcribed correctly.
Failure to Provide Medically-Related Social Services After Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services to address psychosocial well-being, behavioral needs, and follow-up after resident-to-resident incidents for two residents with dementia and mood disorders. One resident (R35) had vascular dementia with severe cognitive impairment, verbal behavioral symptoms toward others, and documented episodes of swearing, resisting care, and verbal and physical aggression toward a roommate. Another resident (R49) had major depressive disorder, generalized anxiety disorder, unspecified dementia with behavioral disturbance, and adjustment disorder, with documented episodes of yelling, verbal aggression, threatening behavior, and refusing care. The facility became aware of an allegation that R49 had been physically and verbally assaulted by R35, and later documentation described R35 becoming verbally aggressive and physically violent with a roommate, including an observation of attempting to hit the roommate through the curtain. Despite these incidents and the residents’ known behavioral and psychosocial conditions, the social services documentation was incomplete and lacked evidence of assessment and follow-up. For R35, social service progress notes since December consisted of only two entries related to family consent for continued medication, without details of the medication. An annual social service progress review for R35 was left incomplete in multiple sections, including cognitive/mental status comments, mood/behavior/emotional status, current mood and behavior status, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, and psychoactive medication review. There was no documented social services follow-up after the resident-to-resident incident in December or after the February incident where R35 became physically violent with the roommate. For R49, only one social service assessment was completed shortly after admission, and no quarterly assessment was available. That assessment was also incomplete, omitting documentation of behavior, medical and psychiatric history impact, admitting and historical behaviors or mood disorders, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, daily foods/drinks, and conflict-handling style, despite the resident being on a psychoactive medication and having a very low BIMS score. Clinical notes documented that R49’s family reported verbal aggression from the roommate and requested room changes, and psych services documented ongoing depression, anxiety, agitation, verbal aggression, and threatening behavior. However, there was no social services follow-up documented after the alleged abuse incident in December, the later roommate conflict, or the psych note describing significant psychosocial distress. Interviews with the Social Service Director revealed uncertainty about how psychosocial needs and behavioral monitoring were assessed and communicated, and the Administrator acknowledged expectations for follow-up that were not met, in contrast to the facility’s policy requiring initial and quarterly assessments, documentation of medically-related social service needs, and monitoring of residents’ mental and psychosocial functioning. The facility’s own policy on social services required the social worker or designee to complete initial and quarterly assessments for each resident, identify and document medically-related social service needs, and ensure that the care plan reflected ongoing psychosocial needs and how they were being addressed. The policy also specified services such as identifying individualized non-pharmacological approaches to meet mental and psychosocial needs and meeting the needs of residents coping with stressful events. In the cases of R35 and R49, the documented omissions in assessments, lack of detailed psychosocial and behavioral information, and absence of follow-up after resident-to-resident incidents and documented behavioral concerns demonstrate that these policy requirements were not followed, leading to the cited deficiency in providing medically-related social services to help each resident achieve the highest practicable quality of life.
Failure to Administer Seizure Medication Accurately and Timely
Penalty
Summary
The facility failed to ensure accurate and timely administration of a prescribed seizure medication for one resident. The resident had diagnoses including other seizures, neuromuscular bladder dysfunction, and multiple muscle contractures, and had a BIMS score indicating severe cognitive impairment. The resident had a physician’s order for Valproic Acid oral solution, 15 ml via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. Review of the MAR showed that on 9/15 the morning dose was documented as given by a nurse, and the evening dose was documented as given by another nurse. However, the facility’s Medication Admin Audit Report revealed that the 7:30 AM dose was actually administered and documented at 12:44 PM, well outside the one-hour before/after window described by the DON, and there was no record on the audit report that the 9:00 PM dose was administered at all. A complaint to the State Agency alleged that on that date the nurse falsified having given the resident their needed seizure medication, resulting in the resident sustaining two seizures during the night, and further alleged that this nurse often provided medications late or not at all. Nursing notes from the early morning of the following day documented that the resident experienced an active seizure at 4:23 AM and a second seizure at 4:23 AM lasting until 4:25 AM, with the resident positioned on the left side and suction available and the physician contacted. During interview, the DON confirmed that the Valproic Acid dose scheduled for 7:30 AM but administered at 12:44 PM was significantly delayed and that, after reviewing the audit, the 9:00 PM dose had not been administered. The facility’s Medication Errors policy stated that medications are to be administered according to physician orders and that time of administration and medication omission are factors indicating errors in medication administration.
Failure to Provide Consistent Supervision for High-Risk Resident
Penalty
Summary
A facility failed to develop and consistently implement an adequate safety plan and provide sufficient supervision for a resident with a significant history of falls and severe cognitive impairment. The resident was admitted with multiple serious injuries from a prior fall, including intracerebral and subdural hemorrhages, spinal and rib fractures, and a right orbital fracture. Upon admission, the resident was noted to be restless, impulsive, and required staff assistance for all activities of daily living, with a care plan that included a one-on-one sitter due to high fall risk. Despite these interventions being documented, the facility did not consistently provide the required one-on-one supervision. Throughout the resident's stay, there were at least ten documented falls, several resulting in injuries such as hematomas, lacerations, and bruising, and requiring emergency department evaluation. Progress notes and interviews revealed that the resident was frequently agitated, difficult to redirect, and continued to attempt to stand or move unassisted. Staff and medical providers repeatedly documented the resident's need for close supervision, yet the one-on-one sitter was removed at some point prior to a significant fall, contrary to the established care plan. Staff interviews confirmed that the removal of the sitter was a management decision, and that the resident's supervision was insufficient during this period. The facility's administration acknowledged to the resident's legal guardian and to surveyors that they could no longer provide the one-on-one supervision as outlined in the care plan, and even requested the guardian to provide or pay for additional supervision. There was no documentation of a revised strategy or adequate alternative supervision plan, and the facility failed to ensure the care plan interventions were followed. The facility's own policy required individualized supervision based on assessed risk, but this was not adhered to, resulting in repeated falls and injuries for the resident.
Failure to Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and a recent clavicle fracture. The resident, who was dependent on staff for most aspects of care, was admitted, readmitted, and later discharged to the hospital following an incident where she claimed to have been pushed from her wheelchair by staff. The allegation was communicated to facility leadership via an email from the Transitional Care Liaison, which included a hospital case manager's note stating that the resident's son found her story inconsistent but agreed to a report being made to Adult Protective Services (APS). Despite being notified of the abuse allegation, the facility did not report the incident to the State Agency as required by both federal regulations and the facility's own policy, which mandates immediate reporting of all abuse allegations. During an interview, the Administrator acknowledged the decision not to report, stating that the team felt the incident did not occur. Facility documentation confirmed that the abuse allegation was not reported to the State Agency, constituting a failure to follow established procedures for reporting alleged violations.
Plan Of Correction
Element 1 - The facility identified resident #803 and they no longer reside at the facility. The administrator during this survey is no longer employed at the center effective 6/19/2025. Element II - The facility identified that all residents residing at the center could be affected by the deficient practice. The facility interviewed all patients who can be interviewed (BIMS>11), to ensure that any potential abuse allegations have been reported. There were no findings to report. Element III - The new facility administrator reviewed and understands the reporting requirements of the abuse policy. The facility educated the transitional care staff on proper abuse reporting methods to promote timely abuse reporting. Element IV - The facility administrator/designee will conduct 3 random interviews, weekly, times four weeks to ensure that all abuse allegations have been identified and reported. The results from those interviews will be submitted to the QAPI committee for review and recommendation. Element V - The administrator is responsible for achieving and maintaining compliance. The compliance date is 7/15/25.
Failure to Monitor and Address Severe Weight Loss in Resident with Malnutrition
Penalty
Summary
Facility staff failed to consistently assess, monitor, and review the nutritional needs of a resident with severe protein-calorie malnutrition, dysphagia, and recent surgical amputation. Upon admission, the resident had a documented history of inadequate energy intake, significant weight loss, and was identified as needing a regular diet with specific supplements and feeding assistance. Despite physician orders for weekly weights, the facility missed obtaining a required weight during the first week, and subsequent weights showed a rapid and significant decline in body weight. Throughout the resident's stay, food intake records indicated that the resident was consuming only 0% to 25% of meals, and multiple notes documented ongoing poor intake, difficulty swallowing, and a preference for fluids over solid foods. Although interventions such as supplements and a modified diet were ordered, the facility did not consistently implement or adjust these interventions in response to the resident's continued weight loss and declining intake. The care plan noted the need for feeding assistance and monitoring for signs of dysphagia, but documentation showed that these needs were not adequately addressed or modified as the resident's condition worsened. The facility's Registered Dietician did not identify or address the resident's significant weight loss until after the resident was transferred to the hospital for extreme weakness, lethargy, and refusal of food and fluids. Additionally, a dietary evaluation following the weight loss was incomplete and lacked documentation of interventions to prevent further decline. The facility's own policy required ongoing evaluation and modification of interventions for significant weight loss, but this was not followed, resulting in a severe weight loss of over 15 pounds within four weeks of admission.
Plan Of Correction
Element I- Resident #305 was identified and no longer resides at the center. All residents who reside at the center have the potential to be affected by the deficient practice. Element II- The facility completed an initial audit that consisted of pulling a PCC report for all residents who triggered for significant weight loss in the past 90 days. The facility reviewed the residents on report to ensure adequate interventions are in place to further weight loss. Element III- During morning clinical meetings, the facility IDT will review the EMR clinical dashboard for any resident who triggers for less than 50% of meal consumption and/or significant weight loss. The IDT will immediately assess the nutritional needs of those residents to ensure adequate interventions are consistently implemented and/or modified to prevent further weight loss. The facility will conduct weekly risk management meetings to complete follow-up on all residents who are identified as having weight loss and/or poor appetite. The facility will educate the RD/Designee, and members of the IDT which includes the DON, MDS, Unit Managers, and the Certified Dietary Manager on the Nutrition Monitoring and Management policy to promptly identify risk and address any concerns regarding weight loss or poor appetite. Element IV- The Registered Dietician/Designee will audit the medical records of 5 residents with triggered weight loss, four times over four weeks, then monthly for three months to ensure the facility is assessing, monitoring, and reviewing nutritional needs and intervention to prevent further weight loss of its residents. The audit results will be given to the administrator who will provide them to the QAPI committee for review and recommendations. Element V- The Administrator is responsible for achieving and maintaining compliance, the compliance date is 6/2/2025.
Failure to Conduct Thorough Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident. The resident was admitted to the facility, later went to the emergency room, and upon return, a review of their clinical record showed a progress note indicating the resident woke up confused and believed there was a man in their room. The facility's investigation file revealed that the only interviews conducted were with the resident's responsible party and two male staff members from the unit. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time of the allegation, the nurse who documented the resident's report, or any other residents. The Administrator/Abuse Coordinator confirmed that no additional staff or residents were interviewed and was unaware of the earlier report made by the resident about a man in their room. The facility's policy required a careful and deliberate investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. The investigation did not meet these requirements, as key staff and potential witnesses were not interviewed, and relevant information was not fully gathered.
Plan Of Correction
Element I: Resident #304 continues to reside in the facility and states that she feels safe. She was physically assessed by the charge nurse and provider. Resident #304 is followed by the facility social worker with no effect to mood or routine noted. The allegation of abuse was investigated and not verified. All residents have the potential to be affected by this citation. Element II: An initial “care concern” audit was completed to ensure that there were not any existing or new allegations of abuse. There was nothing remarkable to report. Element III: The Senior Administrator educated the facility administrator on the facility policy titled, “Nursing Administration...Subject: Abuse and Neglect.” The Senior Administrator also provided education on the contents of a proper investigation, including, but not limited to, reviewing PCC documentation. The facility educated its staff on abuse reporting. Element IV: The Senior Administrator will perform weekly audits on any investigative files should the need arise, to ensure that necessary contents are provided. The findings from those audits will be reviewed by the administrator and submitted to the QAPI committee for review and recommendation. Element V: The Administrator is responsible for achieving and maintaining compliance with
Failure to Timely Assess, Document, and Investigate Resident Fall
Penalty
Summary
A resident with hemiplegia, hemiparesis, and severely impaired cognition required partial to moderate assistance for shower transfers. During a shower, a CNA attempted to transfer the resident alone, despite the resident indicating she needed help. The resident subsequently fell to the floor on her knees and toes. The incident was not documented by the day shift staff at the time of the fall, and there was no immediate assessment or documentation of the event. The fall was only reported later during the midnight shift when the resident self-reported the incident and complained of pain in both lower extremities. An LPN documented the resident's account and provided pain medication, and a STAT x-ray was ordered. However, there was no documentation of a timely assessment or notification of management, the physician, or the resident's responsible party at the time of the fall, as required by facility policy. Further review revealed that the incident report was completed after the fact, and there was no documented investigation to determine the root cause of the fall. The post-fall assessment was initiated but left incomplete and not locked. The DON confirmed that there was no additional documented investigation and could not recall which staff were involved in the transfer or in assisting the resident after the fall. Facility policy required immediate assessment, documentation, and investigation, none of which were completed in a timely manner for this incident.
Plan Of Correction
Resident # 303 is currently not in the facility (unrelated to this citation). Resident 303's root cause for the incident was identified post-incident. The resident was assessed with orders for x-rays of her knee, ankle, hips, and back related to pain. No abnormal findings were identified. The resident's care plan was updated to have 2-person assistance with transfers. CNA no longer employed at the facility. Nurse Tyonna Hayes-King was provided 1:1 education on the Fall Management policy, with emphasis on what is considered an incident, timely assessment of a resident post-fall with investigation to determine root cause analysis, and reporting/documentation of all incident/accidents to the Director of Nursing. All residents have the potential to be affected by the deficient practice. An audit was conducted of all resident incident/accidents from the past 90 days to ensure all residents with incident/accidents were assessed, investigation completed to determine root cause analysis, and documentation, and care plans updated in the resident medical record. The DON/designee spoke with all residents who were able to be interviewed for any incident/accident/falls that have not been reported. None were identified. The DON/designee will review all incident/accidents from the previous day/weekend during daily clinical meetings to ensure residents with incident/accidents have been assessed timely after a fall, and investigation is completed to determine root cause analysis. The DON/unit managers will provide focused oversight during daily rounds on the units and provide educational opportunities and reminders to staff who provide care to residents to ensure any incidents that occur while providing care are immediately reported for investigation. This will include random interviews with residents while rounding daily. By 5/21/2025, licensed nurses and certified nursing assistants will be educated on the Best Practice Fall Management policy with emphasis on what is considered a fall (examples of residents being lowered to the floor), head-to-toe assessments of residents in a timely manner, investigations to determine root cause analysis, and reporting of incident/accidents. The DON/designee will audit all risk management reports weekly for 4 weeks and then monthly for 3 months or until substantial compliance has been maintained to ensure that nurses are following the policy for risk management and falls, with emphasis on assessing residents in a timely manner and investigation to determine root cause analysis for falls. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
Failure to Obtain STAT Laboratory Services as Ordered
Penalty
Summary
The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.
Plan Of Correction
Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
A resident was admitted to the facility and later reported to have been sexually abused. The clinical record showed that the resident expressed confusion and reported to a nurse that she believed a man had been in her room. Subsequently, while at the hospital, the resident alleged to police that she had been raped by a male caregiver, but later denied the allegation. The facility's investigation file indicated that only the resident's responsible party and two male staff members from the unit were interviewed. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time, the nurse who documented the initial report, or other residents. The facility's abuse and neglect policy required a thorough investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. However, the investigation did not include interviews with all potentially relevant staff or residents, and the Abuse Coordinator was unaware of the initial report made by the resident to the nurse. The documentation and investigation process did not meet the facility's stated policy requirements for a careful and deliberate investigation.
Inadequate Infection Control for MRSA Case
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for all 82 residents, as evidenced by the mishandling of a MRSA infection case. A resident was informed by their dermatologist that a culture from a cyst on their head tested positive for MRSA, a contagious infection. Despite being placed on contact precautions and started on an antibiotic, the facility did not adequately clean the resident's room or ensure staff wore appropriate protective equipment. The resident reported that staff were not wearing gowns during care and that the facility did not notify external providers about the infection when the resident was transported for physical therapy and other appointments. The facility's infection control surveillance program was found lacking, with no infection control data, including surveillance, line listing, mapping, and analysis reports, available for November 2024, December 2024, and January 2025. The Director of Nursing was unaware of the MRSA case and any potential trends in the facility, and the Infection Control Preventionist was absent during the survey. The Administrator confirmed that the last Quality Assurance meeting did not review November's infection control report, and no additional data was provided before the survey concluded. The facility's policy on infection prevention and control mandates ongoing monitoring and documentation of infections, which was not adhered to in this case.
Failure to Maintain Hot Water Supply Due to Lack of Boiler Inspections
Penalty
Summary
The facility failed to maintain proper functioning of the hot water supply, affecting all 82 residents. The deficiency was identified when it was reported that the facility had no hot water from January 11 to January 16, 2025, due to both hot water boilers failing. During an interview, the Maintenance Director (MD C) confirmed the lack of hot water and revealed that the boilers had not undergone the required CSD-1 inspection in 2024. The inspection was delayed because the boilers needed maintenance and cleaning, and although a quote was sent to the corporate office, no further action was taken. The facility's preventive maintenance policy requires regular inspections and maintenance of equipment, including boilers, to ensure compliance with applicable codes. However, the facility did not have documentation of the annual CSD-1 inspection for 2024 or 2023, only a receipt of service. The CSD-1 code mandates that controls and safety devices of boilers be tested annually, and the facility failed to comply with this requirement, leading to the prolonged hot water outage.
Failure to Document and Follow Up on MRSA Diagnosis
Penalty
Summary
The facility failed to ensure that the physician evaluated the total program of care for a resident, specifically regarding a newly developed skin impairment. The resident, who had a history of type 2 diabetes mellitus and lymphedema, reported a pus-filled blister on his scalp to the attending physician. The physician initially dismissed it as a common condition for diabetics and prescribed an antibiotic, Keflex, without documenting the condition properly in the medical records. The resident, concerned about the unusual nature of the blister, sought a second opinion from a dermatologist, who diagnosed the condition as MRSA, a contagious infection. Despite the dermatologist's diagnosis and the resident's notification to the facility, the attending physician failed to document the MRSA diagnosis or the treatment plan in the medical records. Progress notes from the physician repeatedly indicated no new concerns and did not mention the skin impairment or the MRSA diagnosis. The resident's medical records showed orders for antibiotics and contact precautions for MRSA, but these were not reflected in the physician's documentation. Interviews with the physician and the Director of Nursing revealed a lack of thorough documentation and follow-up on the resident's condition. The physician admitted to a documentation error and could not provide evidence of proper assessment or follow-up for the skin impairment. The Director of Nursing confirmed that the facility's expectations for physician evaluations were not met, as the documentation lacked accuracy and thoroughness regarding the resident's change in condition.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, specifically in the areas of regular bathing and transfers. The resident, identified as R803, was observed waiting for assistance to transfer from their bed to a wheelchair for approximately two hours. The resident reported that the CNA was aware of their need but did not return to assist after helping another resident with eating. The resident also indicated that they rarely received showers due to the staff's reluctance to help them, despite needing maximal assistance for such tasks. The medical record review revealed that R803 had only received two showers since their admission, with no documented refusals of showers, except for two instances where the resident chose not to have their hair washed. The Director of Nursing confirmed that residents should be offered showers at least twice a week and that staff should document when a shower is provided or refused. However, there was no additional documentation to support that R803 had been offered or provided scheduled bathing as required.
Failure to Monitor and Document Skin Impairment and MRSA Diagnosis
Penalty
Summary
The facility failed to properly identify, monitor, and assess a skin impairment for a resident, R802, who had consulted with a physician about bumps on his scalp. Despite being informed by the resident that the bumps were spreading and having a dermatologist appointment, the facility did not document any skin impairments on the resident's head or scalp. The resident was later diagnosed with MRSA by the dermatologist, but this information was not adequately followed up by the facility. Interviews and record reviews revealed that the resident had informed the facility of his dermatologist appointment and provided the paperwork to a registered nurse. However, there was no documentation of the skin impairment in the resident's clinical record, and the facility's staff, including the attending physician and the Director of Nursing, were unaware of the MRSA diagnosis. The facility's protocols for documenting and following up on new skin impairments were not adhered to, as evidenced by the lack of documentation and assessment of the resident's condition. The facility's failure to document and follow up on the resident's skin condition and MRSA diagnosis was further compounded by the lack of communication and coordination among the care team. The attending physician and registered nurse provided conflicting accounts of the resident's treatment, and the Director of Nursing was unaware of the MRSA diagnosis despite existing physician orders for treatment and contact precautions. This lack of documentation and follow-up highlights a significant deficiency in the facility's care and monitoring processes.
Failure to Return Residents' Clothing Timely
Penalty
Summary
The facility failed to ensure that personal clothing items sent to the laundry were returned to residents in a timely manner. During a Resident Council meeting, several cognitively intact residents reported missing clothing items, including green shirts, pants, and other personal garments. Despite reporting these issues, the residents did not receive their clothing back nor compensation to replace them. Past Resident Council Minutes also documented similar grievances, indicating a pattern of missing clothing items and delayed returns. Interviews with facility staff revealed awareness of the issue. The Activity Director acknowledged the complaints and stated that grievance forms were completed and forwarded to the Administrator. Laundry staff, employed by an outside company, noted that the problem often arose from facility staff failing to label clothing bags with residents' names and room numbers, making it difficult to return items correctly. The Housekeeping Director confirmed the issue, showing the surveyor bins of unlabeled laundry, which complicated the return process. The Administrator recognized the problem and mentioned that some residents or their families were reluctant to label clothing, although alternative solutions were acknowledged.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a medication administration session with an LPN. Loose, unidentifiable medications were found in the medication cart labeled as Cart C Hall. Specifically, the cart contained several loose pills, including a round white pill with no identifier, two round white pills stamped 337, a half peach-colored pill, a round pink pill stamped R50, a quarter white pill, a round pink pill stamped IG/207, and a half white round pill. The LPN acknowledged that these medications were not properly stored and should not be loose without patient identifiers. Additionally, the medication room identified as Traverse had two stacked refrigerators, with the top refrigerator storing insulin lacking a thermometer and temperature logs. The LPN confirmed that the refrigerator's temperature should be monitored and recorded, but was unsure why the thermometer was missing. The Director of Nursing was informed of these observations and acknowledged the need for temperature monitoring in the refrigerator and proper storage of medications in the cart. The facility's policy on medication access and storage, dated July 2018, requires medications needing refrigeration to be kept in a refrigerator with a thermometer for temperature monitoring.
Contaminated Linen Storage in Laundry Room
Penalty
Summary
The facility failed to maintain clean storage of linens and resident clothing in the laundry room, leading to contamination with dust and dryer lint. During a tour of the laundry room, two linen carts containing clean folded linens, comforters, and clothing were observed to be covered with large amounts of thick white fuzzy debris. The right cart's green protective sheet panel was lifted to reveal a cardboard box and wheelchair adaptive equipment also covered with the debris. The left cart had folded cardboard boxes used as a top shelf, which were covered with dusty material, and a half-consumed water bottle was found on it. Housekeeping Manager B and Assistant Housekeeping Manager C acknowledged the presence of clean laundry on the carts and confirmed the contamination with dust and dirt, deeming the conditions unhygienic. The facility was unable to provide a clean laundry storage policy by the end of the survey.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident with Chronic Obstructive Pulmonary Disease and Adjustment Disorder, who was independent in most activities of daily living and had intact cognition. The resident alleged that a Certified Nursing Assistant (CNA) verbally threatened him with physical harm during an altercation at the nurse's station. The resident reported that the CNA told him she would 'beat his ass' after he refused to leave the nurse's station and began swearing at her. Witnesses, including another CNA and a receptionist, confirmed hearing the CNA use threatening and abusive language towards the resident. The facility's investigation included interviews with the involved parties and a review of the resident's medical record and the CNA's personnel file. The CNA admitted to using inappropriate language but denied making any threats. However, both the receptionist and another CNA corroborated the resident's account, stating they heard the CNA use threatening language. The facility determined that the CNA violated multiple work rules, including using profane language and failing to show respect to the resident. The Director of Nursing acknowledged that the CNA's behavior was unprofessional and confirmed that the CNA was terminated for multiple violations of work rules. The facility also conducted a house-wide re-education of staff on abuse and neglect policies to prevent future incidents. The facility's policy on resident rights and abuse was reviewed, emphasizing the importance of providing care in an environment free from any type of abuse, including verbal abuse.
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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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