Medilodge Of Westwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalamazoo, Michigan.
- Location
- 2575 N Drake Road, Kalamazoo, Michigan 49006
- CMS Provider Number
- 235542
- Inspections on file
- 27
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medilodge Of Westwood during CMS and state inspections, most recent first.
A resident with multiple serious comorbidities and intact cognition was discharged home despite repeatedly stating she could not safely enter her house or care for herself, and despite her family’s clear objections and inability to prepare the home environment. Staff, including RNs and therapy, documented and reported that the resident was distraught, crying, and fearful about going home, and one RN refused to sign the discharge paperwork due to safety concerns. The facility proceeded with discharge after managed care coverage ended, requiring advance private payment and refusing a personal check, while a second-level insurance appeal was still in process. On arrival home, the transport driver could not get the resident’s wheelchair through the doorway and noted additional obstacles inside, leading the family to call an ambulance and the resident to be sent to the hospital, demonstrating that the discharge planning process did not ensure a safe and appropriate transition.
Two residents with significant mobility and cognitive impairments did not receive adequate supervision or consistent implementation of care planned fall prevention interventions. One resident suffered a fall resulting in a fracture after being found unsupervised in a hallway, with required safety equipment not in place. Another resident was transferred by a CNA without the use of a gait belt or prescribed walker, contrary to care plan and facility policy.
The facility did not adequately follow up or resolve grievances related to missing personal items for several residents, with incomplete documentation and lack of communication regarding investigation outcomes. Residents, including those with cognitive and visual impairments, reported missing money, clothing, and unauthorized debit card charges, and staff interviews confirmed that investigations and resolutions were not consistently completed or communicated.
Multiple failures in infection prevention and control were observed, including lack of proper PPE use and signage for residents requiring enhanced barrier precautions, inadequate hand hygiene and glove use during insulin injections, and unclean shared equipment. These lapses involved residents with wounds or surgical sites and staff who were unaware or did not follow required protocols, increasing the risk of infection transmission.
Surveyors identified multiple deficiencies in environmental safety and sanitation, including moisture accumulation and insect presence in the kitchen, unsanitary conditions and missing supplies in shower and utility rooms, and unclean, poorly maintained resident rooms. Staff interviews confirmed lapses in cleaning routines and maintenance reporting.
Two residents experienced a lack of dignified dining when they were not served their meals in a timely manner while others at their table were already eating. One resident waited so long that he ate leftover bread from another's place, and another left the table with her meal untouched after finally being served. The Regional Registered Dietitian confirmed that such delays were not normal and that residents seated together should receive meals at the same time.
Two residents with complex medical needs were discharged without being provided the required SNF-ABN and NOMNC forms. Due to a transition in social services leadership, the forms were not completed or documented, and staff were unable to produce them during the survey.
The facility did not provide required discharge notifications to the State LTC Ombudsman for two residents who were transferred to the hospital. Documentation confirmed the transfers, but the ombudsman's office had not received notifications for several months. Interviews indicated a lack of clarity regarding staff responsibilities for this process.
A resident was inaccurately coded as having schizophrenia on the MDS assessment, despite no evidence of psychosis-related behaviors or treatment for schizophrenia. Staff interviews confirmed the resident was not being treated for this condition, and the diagnosis was based on outdated documentation rather than current clinical findings.
Two residents did not receive physician-ordered medications and wound care treatments as documented, with staff admitting to false documentation and failure to notify providers of missed doses or treatments. One resident with psychiatric diagnoses missed an antidepressant dose without provider notification, while another with a surgical wound did not receive required dressing changes despite records indicating completion. Nursing staff confirmed lapses in documentation and communication, contrary to facility policy and professional standards.
A resident with hemiplegia and reduced mobility was repeatedly observed with greasy, unkempt hair and wearing the same clothing, despite scheduled showers and bed baths. Staff interviews revealed that hair washing was expected as part of ADL care but was not consistently performed or documented, and the resident reported her hair was not washed as often as she preferred. Documentation gaps and lack of clarity among staff contributed to the resident's unmet hygiene needs.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with a mental health disorder missed doses of prescribed Wellbutrin due to staff not locating available medication and failing to notify the provider, with inaccurate documentation of administration. Another resident with a recent foot amputation and diabetic wound did not receive ordered wound care, as dressing changes were omitted for several days without documentation of refusal. Nursing staff confirmed treatments were not provided as ordered, and required documentation and provider notifications were not completed.
A resident with right-sided contracture following a stroke did not consistently receive prescribed hand splinting and positioning devices as outlined in the care plan and Kardex. Observations showed the resident without any splint, and interviews with a CNA and LPN revealed they were unaware of the need for such devices. No documentation was found to indicate the devices were applied, despite care plan directives.
Two residents did not receive safe respiratory care as required: one received supplemental oxygen at a rate higher than the physician-ordered range, with the nasal cannula sometimes improperly applied, while another used a CPAP machine without an active physician order and with inadequate cleaning of the mask and straps. Staff interviews and documentation revealed inconsistent practices and lack of adherence to facility policy regarding respiratory care.
A resident with end stage renal disease who required dialysis did not have post-dialysis assessments and monitoring completed or documented as required. Nursing staff confirmed that vital signs, weight, and access site checks were expected after dialysis, but records showed these were not performed or recorded for several months after related orders were discontinued. The DON acknowledged the lack of documentation and missing orders for post-dialysis monitoring.
Two residents with significant trauma histories did not have their trauma triggers identified or addressed in their care plans. One resident with a history of psychiatric illness, substance use, and recent amputations, and another who lost her home and pets in a fire, both lacked trauma-informed interventions. Staff were not informed of their trauma histories, and social services did not conduct adequate trauma assessments or referrals, resulting in unmet emotional needs and the potential for re-traumatization.
A resident with anxiety and depression, admitted for rehabilitation after a traumatic event, did not receive ordered psychological support services. Despite a physician's order and care plan interventions for behavioral health, the resident was not referred to counseling or psychological services, and the DSS was unaware of the order.
Two residents experienced medication errors when a nurse administered insulin from a pen past the recommended discard date and failed to provide a scheduled antidepressant dose due to not checking all storage areas. Additionally, a resident received the wrong opioid medication, with inaccurate documentation. These actions led to a medication error rate above 5%.
Staff failed to store and manage medications according to manufacturer and facility guidelines, including using insulin pens beyond recommended discard dates, leaving an inhaler unsecured in a resident's room, and maintaining a disorganized medication cart. These actions resulted in medications being administered past their safe usage period and improper storage of drugs and biologicals.
Surveyors found that food items brought in by family and visitors for a resident were not consistently labeled with opened or discard dates, and some items were stored past their safe consumption period. The facility's policy required labeling and timely consumption of such foods, but this was not followed, as confirmed by the RRD during an interview.
Two residents in a LTC facility experienced preventable falls due to inadequate supervision and improperly secured equipment. One resident, with Alzheimer's and a history of falls, was left unattended despite requiring 1:1 supervision, resulting in a head injury. Another resident fell out of bed when an enabler bar was not properly engaged, causing a skin tear. Both incidents highlight lapses in safety protocols.
The facility did not adequately address resident concerns about long call light wait times, as documented in Resident Council Minutes and confirmed by resident and staff interviews. Residents reported waiting up to an hour for responses, particularly during understaffed shifts, leading to dissatisfaction and potential care issues.
The facility failed to serve food at a palatable temperature, leading to dissatisfaction among two residents with type 2 diabetes. Both residents, who were cognitively intact, reported that meals were often not hot enough, especially breakfast. Staff interviews confirmed these complaints, and temperature logs lacked documentation for certain days, indicating a failure to ensure food was served at a safe and appetizing temperature.
The facility failed to provide two residents with the food items they requested, leading to dissatisfaction and potential nutritional decline. A resident with diabetes did not receive the correct breakfast items or substitutions for items she did not eat. Another resident did not receive the cottage cheese she ordered. Staff reported frequent complaints about incorrect meal deliveries and communication issues with the kitchen.
A resident with severe cognitive impairment and multiple health issues was not administered oxygen as per physician orders. Observations showed the oxygen concentrator was off and tubing improperly stored. Staff interviews revealed confusion about the resident's oxygen orders, with a CNA adjusting the concentrator to the correct flow rate after noticing it was set incorrectly.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illness for 87 residents. Observations revealed a reach-in refrigerator with temperatures above the recommended 41°F, packed with food. The Maintenance Director's attempts to fix the issue increased temperatures further. The Dietary Director discarded perishable items, and a follow-up found improper storage and unidentified solutions in the kitchen, violating FDA Food Code standards.
The facility failed to control hot water temperatures in the B hall, with measurements showing 127°F in the shower room and 128°F in the utility room, exceeding the safe limit of 120°F. The Maintenance Director confirmed that each hall has its own hot water system, and there were no mixing valves to temper the water. Maintenance staff typically checks temperatures in the morning but does not track fluctuations throughout the day.
The facility failed to implement proper infection control protocols, including Enhanced Barrier Precautions, for residents with indwelling devices. Staff did not consistently use PPE, and medical equipment was inadequately cleaned, posing risks of infection. Observations revealed improper wound care practices and poorly maintained resident equipment, indicating systemic issues with infection control.
The facility failed to protect residents from abuse, involving two cognitively impaired residents who engaged in verbal and physical altercations. One resident, with a history of aggression, admitted to slapping another and continued to exhibit inappropriate behavior without adequate supervision. Staff were unable to prevent a physical altercation despite attempts to intervene, and ongoing concerns about the residents' interactions were noted.
The facility failed to prevent further abuse during an ongoing investigation involving two cognitively impaired residents. One resident, with a history of aggressive behavior, was not adequately monitored, leading to a physical altercation with another resident. Despite interventions in place, the facility did not effectively supervise or separate the residents, resulting in repeated conflicts.
The facility failed to provide required transfer/discharge notices to two residents when they were transferred to the hospital. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews revealed a lack of adherence to the facility's policy on transfer notices.
The facility failed to provide two residents with a written bed hold policy notice upon their transfer to a hospital, as required by the facility's policy. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews confirmed the absence of such notices in their records.
A resident with severe sepsis and cellulitis received IV antibiotics inconsistently, with all doses administered outside the prescribed timeframe. Nursing staff interviews revealed confusion about administration times, and the Medication Administration Record showed significant deviations from the recommended schedule.
A resident with pyogenic arthritis experienced worsening knee pain and was unable to walk safely, yet the facility failed to provide a wheelchair despite the resident's requests. Staff interviews revealed a lack of awareness and communication regarding the resident's increased needs, resulting in struggles with mobility, incontinence, and personal hygiene.
A resident with cognitive impairment and a history of heart and respiratory failure did not receive necessary care for pressure ulcers, resulting in infrequent dressing changes and potential infection. The care plan required daily dressing changes, but observations showed dressings were not changed as ordered. Interviews with the resident and family member expressed dissatisfaction with care, and documentation was inconsistent, indicating a lapse in care.
A facility failed to maintain communication and documentation for a resident with end-stage renal disease who required dialysis. The resident's dialysis communication binder was missing, and no communication forms had been received or documented in the medical record for three months. Staff interviews confirmed the lack of communication and documentation, and the facility could not provide any records of communication with the dialysis center during this period.
Two residents experienced medication administration errors, leading to a 16% error rate. One resident did not receive prescribed medications due to unavailability, while another received an incorrect dose of Fexofenadine. These incidents reflect the facility's failure to maintain a medication error rate below five percent.
The facility failed to ensure proper medication storage and administration for two residents. A nurse left medications, including controlled substances, unattended at the bedside without observing the residents taking them. Neither resident had orders or assessments for self-administration, and their care plans lacked focus on self-administration. The DON confirmed no residents were authorized to self-administer medications.
A resident's pressure ulcer care was inadequately documented and not performed as scheduled, leading to potential issues in follow-up care. Family concerns and staff interviews revealed that wound dressings were not changed daily as required, with discrepancies in the Treatment Administration Record and observed dressing dates.
Two residents in the facility experienced unclean living conditions, with rooms and bathrooms having odors of urine, sticky floors, and flying insects. One resident, with dementia and anxiety disorder, had a room with persistent cleanliness issues, while another resident, with bladder-neck obstruction, struggled with managing a urinary drainage bag, leading to leaks and further uncleanliness. The facility's housekeeping efforts were insufficient, as noted by the District Housekeeping Manager and Interim Nursing Home Administrator.
Unsafe Discharge Home Despite Resident and Family Objections
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a cognitively intact female resident with multiple serious medical conditions, including left lower limb cellulitis, diabetes, morbid obesity, peripheral atherosclerosis with gangrene, heart disease, hypertension, anemia, anxiety, and severe chronic kidney disease. Her care plan documented that she planned to discharge home, with interventions to involve her and her family in discharge planning, coordinate home care agencies and community supports, and provide written instructions for a safe return to the community. Despite this, the discharge planning process did not adequately address her and her family’s expressed concerns about the safety and feasibility of returning home, particularly regarding access to the home and the availability of care. In the days leading up to discharge, the resident, her family member, and multiple staff members reported significant distress and concern about the planned discharge home. The resident’s MDS showed she was cognitively intact, and she repeatedly stated she could not go home and could not get into the house, which was corroborated by a physical therapy note documenting that she was very emotional and requesting to stay longer. The family member told staff, including the DON, that the resident was in no condition to be discharged and that there was no way to get the resident into the home due to an electric wheelchair blocking the door and the resident’s own wheelchair being too wide. Nursing staff, including RNs, reported that the resident was distraught, crying, and verbalizing that she could not care for herself and would have to call 911 after discharge. Staff nurses expressed that they did not feel safe discharging her and one RN refused to sign the discharge paperwork because she felt it was inappropriate. Financial and insurance issues were central to the decision to proceed with discharge despite these concerns. The business office manager reported that the resident’s managed insurance coverage ended with a last covered day and that a Notice of Medicare Non-Coverage was issued and appealed, with the first appeal rejected. The facility informed the resident and family that, without a secondary payer source, continued stay would require private payment in advance, and the DON and regional director stated that facility policy did not allow acceptance of personal checks for room and board, requiring cash, debit/credit card, or certified check. The family member attempted to pay the requested amount with a personal check but was told it would not be accepted and was unable to obtain a certified check before the scheduled discharge. Despite ongoing appeals and later confirmation that a second-level appeal had been approved, the facility proceeded with the planned discharge when transportation arrived. On the day of discharge, multiple staff and the transport driver observed that the resident was upset, crying, and apprehensive, and upon arrival at home, the wheelchair would not fit through the door and the path inside was blocked, leading the family member to call an ambulance and the resident to be rehospitalized. These events demonstrate that the facility did not ensure the discharge plan met the resident’s needs and preferences or that she was prepared for a safe transfer home, as required by its discharge planning policy.
Failure to Implement Fall Prevention and Supervision Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent accidents for two residents. One resident with a history of dementia, multiple fractures, unsteadiness, and cognitive deficits was care planned for fall prevention measures, including keeping the bed in a low position, using a fall mat, ensuring the call light was within reach, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall in the hallway, was found sitting on the floor, and later was diagnosed with a closed fracture of multiple pubic rami. Observations after the fall revealed that the fall mat was not consistently placed next to the bed as required, and the wheelchair was not within reach. The resident was also observed unsupervised in the dining room, attempting to pick up items from the floor without staff present, despite her impulsiveness and cognitive impairment. Another resident with a history of stroke, right-sided paralysis, muscle weakness, and reduced mobility was care planned for two-person assistance with transfers and ambulation, and the use of a gait belt for safety. During an observed transfer, a CNA assisted the resident from the wheelchair to the bed without using a gait belt and did not utilize the prescribed walker. The resident was prompted to hug the CNA for support during the transfer, and the wheelchair was placed out of reach afterward. The facility's policy and staff interviews confirmed that a gait belt should be used for all transfers involving residents who are weak or unsteady. The facility's fall prevention program required that residents at risk for falls receive care and services according to their assessed risk, and that interventions be monitored for effectiveness and revised as needed. However, direct observations and interviews indicated that care planned interventions were not consistently implemented for both residents, resulting in a fall with injury for one and the potential for harm for the other.
Failure to Resolve and Communicate Outcomes of Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for multiple residents regarding missing personal items, including money, clothing, and other belongings. Documentation for grievances submitted by residents was incomplete, with forms lacking information on whether concerns were resolved, if results were communicated to residents, and whether residents were satisfied with the outcomes. In several cases, there was no evidence that investigations were completed or that residents were informed of the findings, despite facility policy requiring such actions. Residents reported missing items such as cash, clothing, and personal care items, and in one case, a resident with visual impairment reported unauthorized charges on his debit card after staff assisted him with purchases. Interviews with staff revealed that some were not involved in investigations or were unaware of the outcomes, and that the previous administrator was responsible for handling certain incidents but did not complete the required documentation. Resident Council minutes and group interviews further confirmed that concerns about missing items and unresolved grievances were ongoing and not addressed in a timely or effective manner. The facility's Quality Assistance Policy required that grievances be investigated, findings reported to the administrator, and results communicated to the resident or their representative. However, review of records and interviews indicated that these steps were not consistently followed. The lack of a specific policy regarding missing items and the absence of thorough documentation and communication contributed to the deficiency, resulting in unresolved grievances and dissatisfaction among residents.
Failure to Implement Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols for multiple residents, specifically regarding enhanced barrier precautions (EBP), injection practices, and the handling of soiled shared equipment. For three residents requiring EBP due to wounds or surgical sites, there were lapses in the use of personal protective equipment (PPE), signage, and care plan documentation. One resident with a deep tissue injury to the left heel had a care plan indicating the need for EBP, but no interventions were listed, and the EBP signage was inconsistently posted. Another resident with a right foot surgical incision had orders and care plans specifying EBP, but staff were observed providing high-contact care without donning the required PPE, and the EBP sign was missing until after surveyor intervention. A third resident with a coccyx wound had no EBP signage or care plan documentation, and an LPN provided direct care without PPE, stating she was unaware of the EBP requirement. Additionally, infection control practices during medication administration were not followed. A nurse was observed preparing and administering an insulin injection without performing hand hygiene or wearing gloves, and later reported that she did not typically use gloves for injections, nor was she trained to do so. This practice deviates from standard infection control protocols and increases the risk of cross-contamination. The facility also failed to ensure that shared equipment was properly cleaned between uses. A hoyer lift was observed in the hallway with a resident grasp cover that had dried, soiled material, indicating it had not been cleaned after use. These deficiencies collectively increased the potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents.
Failure to Maintain Sanitary and Safe Environment in Multiple Facility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, as evidenced by direct observations and staff interviews. In the kitchen, worn and missing grout, as well as raised tiles under the dish machine and garbage disposal, allowed moisture to accumulate, creating conditions conducive to insect and bacterial growth. Multiple gnats were observed in these areas, particularly around an unused floor drain and sections with low grout. The lack of a functioning exhaust for the high-temperature dish machine further exacerbated moisture accumulation and humidity in the area. During a tour of resident care and utility areas, additional deficiencies were noted. In the B hall shower room, crusted white powder debris was found on the commode seat, and there was no paper towel holder or paper towels available. The shower bed had accumulated trash, debris, and staining under the mat, with care staff reportedly responsible for cleaning between residents. In the central supply room, boxes of briefs were stored directly on the floor, and shelving units were made of press-board that was not smooth or easily cleanable. The C Hall Soiled Utility room had vinyl coving that had fallen and lacked proper structural support, while the D Hall Soiled Utility room had a non-functioning exhaust fan, affecting the entire hall. Resident rooms were also found to be unsanitary and in disrepair. Observations included dried liquid spills and brown stains on floors and walls, cobwebs and dust on window sills and blinds, and dirty thresholds. One room had a wall bead strip detached and leaning against the wall, chipped paint on the heater, cracks on the wall, and exposed nails or screws. Housekeeping staff described a multi-step cleaning process but noted that rooms could be skipped if residents were present, and maintenance issues were reported through an electronic work order system.
Failure to Provide Dignified Dining Experience Due to Delayed Meal Service
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents by not serving their meals in a timely manner while others at their table were already eating. During a dining observation, one resident was served and began eating, while another at the same table waited without a meal. Two more residents joined, and one of them received his meal and finished eating before the two waiting residents were served. One of the waiting residents eventually took uneaten bread left by another and began to eat it, while the other left the table with her meal untouched after finally being served. The last resident was served his meal after being left alone at the table. The Regional Registered Dietitian confirmed that residents seated together should receive their meals at the same time or as soon as possible, and that waiting 20 minutes or more was longer than normal.
Failure to Provide Required Medicare Coverage Notices to Discharged Residents
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-coverage (NOMNC) forms to two residents prior to their discharge. Both residents had significant medical conditions, including metastatic lung cancer, COPD, malnutrition, and cognitive deficits. Review of records and interviews confirmed that these forms were not issued as required, and no documentation of the forms could be located for either resident. The Social Services Director, who became responsible for issuing these forms in mid-February, reported that she did not provide the SNF-ABN or NOMNC forms to the affected residents prior to their discharge. The Regional Director of Operations also confirmed that, due to a transition in social services leadership during the residents' stays, the required forms were not completed and could not be found. No copies of the SNF-ABN or NOMNC forms were provided to surveyors for either resident by the time of the survey exit.
Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for two residents who were transferred to the hospital. In both cases, documentation showed that the residents were sent to the emergency department or hospital, and all physician orders were discontinued for one of the residents. The State LTC Ombudsman reported not receiving any discharge notifications from the facility for several months. Interviews revealed that the social worker was not involved in notifying the ombudsman's office and had only recently received official training, while the nursing home administrator stated that the social worker was responsible for these notifications and that reports should be sent monthly. As a result, the required notifications to the State LTC Ombudsman regarding resident discharges were not completed.
Inaccurate Schizophrenia Diagnosis Documented on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their current status, resulting in an inaccurate diagnosis of schizophrenia being documented on the Minimum Data Set (MDS) assessment. The MDS for the resident indicated an active diagnosis of schizophrenia, despite no evidence of psychosis-related behaviors during the assessment period and no treatment or prescription of antipsychotic medication for schizophrenia while at the facility. The resident's medical diagnosis list included schizophrenia, but this was based on a historical entry and not on current clinical findings. Interviews with facility staff confirmed that the resident was not being treated for schizophrenia and had no related behaviors observed. The social worker stated that the resident's depression medication was managed by a psychiatrist, but there was no treatment for schizophrenia. The MDS nurse acknowledged that the resident was coded as having schizophrenia on the MDS, despite the absence of supporting clinical evidence or treatment. Review of the MDS 3.0 RAI manual emphasized the requirement for accurate assessments based on validated information from the observation period, which was not met in this case.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice regarding the administration and documentation of physician-ordered medications and treatments for two residents. For one resident with a history of bipolar disorder, depression, and suicidal ideation, the Medication Administration Record (MAR) indicated that an antidepressant medication was administered on specific dates, but a nurse admitted to falsely documenting the administration when the medication was not actually given. There was also no documentation that the provider was notified of the missed dose, as required by professional standards and facility policy. For another resident with a complex medical history including a right foot amputation, diabetes, and impaired skin integrity, the Treatment Administration Record (TAR) showed multiple omissions in the documentation and completion of wound care treatments as ordered by the physician. Observations revealed that the resident's wound dressing had not been changed for several days, despite documentation indicating otherwise. The wound care nurse confirmed that the dressing had not been changed since a specific date, and the wound was observed to be swollen and at risk of dehiscence. There was no documentation of treatment refusals or provider notification regarding missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that treatments and medications were not administered or documented according to orders and policy. Staff acknowledged that refusals and missed treatments were not consistently documented, and that provider notification did not occur as required. Facility policy and professional nursing standards require accurate documentation and timely communication with providers regarding missed medications and treatments, which was not followed in these cases.
Failure to Provide Adequate ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a dependent resident, specifically in the area of hair care. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and required assistance with personal care and had reduced mobility, was observed on multiple occasions with greasy and unkempt hair. Documentation showed that showers or bed baths were scheduled and recorded on certain days, but there were gaps in documentation and no record of refusals or incomplete care. The resident reported that her hair was not being washed as frequently as she preferred, and staff interviews confirmed that hair washing was expected to be part of shower or bed bath routines, but it was not always performed or documented. Observations over several days revealed the resident wearing the same clothing and with consistently greasy hair, despite scheduled care. Staff interviews indicated confusion or lack of clarity regarding whether hair washing had been completed, and there was no separate documentation for shampooing in the CNA records. The care plan indicated a preference for bed baths, but there was no evidence that hair care was consistently provided as part of this routine. The lack of documentation and inconsistent care led to the resident's unkempt appearance and unmet personal hygiene needs.
Failure to Administer Medications and Provide Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with physician orders and professional standards, as evidenced by two separate incidents involving two residents. In the first case, a resident with a history of bipolar disorder, depression, and suicidal ideations did not receive her prescribed Wellbutrin XL 150 mg for depression as ordered. During a medication administration observation, the registered nurse reported the medication was not available and did not notify the provider or search for extra medication in the designated area. Further review revealed inconsistent documentation, with one nurse falsely documenting administration of the medication and later admitting the error. The medication had been available in the medication cart, but it was not administered as ordered, and the provider was not notified of missed doses. The nurse practitioner was unaware of the missed doses, despite the resident's complex psychological needs and recent medication adjustments due to worsening symptoms. In the second case, a male resident with a right foot trans metatarsal amputation, diabetes, and a history of foot ulcers did not receive wound care as ordered. The resident's care plan and physician orders specified twice-daily wound care, including cleansing and application of Bacitracin Zinc Ointment, as well as daily monitoring for signs of infection. However, review of the treatment administration record (TAR) revealed multiple omissions in the documentation and completion of wound care treatments. During an observation, the wound care nurse discovered that the resident's dressing had not been changed for several days, with the last documented change occurring several days prior. The nurse confirmed that the dressing should have been changed twice daily, as ordered, and that the omission was not due to resident refusal, as no refusals were documented in the record. Interviews with nursing staff and the director of nursing confirmed that treatments were not provided as ordered and that refusals, if they had occurred, were not documented according to facility policy. The facility's wound management policy requires that wound treatments be provided in accordance with physician orders and that refusals be documented and communicated to the provider. The failure to administer medications and provide wound care as ordered resulted in residents not receiving care in accordance with professional standards and physician directives.
Failure to Apply and Document Prescribed Positioning Devices for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a positioning device was consistently applied for a resident with a right-sided contracture following a stroke. The resident's care plan and Kardex specified that a right upper extremity hand splint should be applied for four hours daily in the morning and a carrot splint should be used as tolerated during the day and night. However, during multiple observations, the resident was seen without any splint or positioning device on his right hand. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any splint or device to be used for the resident, and the CNA reported never having seen a splint on the resident in her seven months at the facility. Further review of the resident's medical record showed no documentation that the splint or carrot device had been applied as directed in the care plan and Kardex. The Senior Director of Nursing confirmed that the care plan and Kardex included instructions for splinting, and that staff should have documented the application of these devices, but there was no such documentation present. This lack of consistent application and documentation of the prescribed positioning devices constituted a failure to provide appropriate care to maintain or improve the resident's range of motion.
Failure to Ensure Safe Respiratory Care and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to oxygen administration and CPAP use. For one resident with a history of hemiplegia, hemiparesis, and congestive heart failure, observations revealed that her oxygen concentrator was consistently set above the physician-ordered range of 2-4 liters per minute, with settings noted at 4.5 to 5 liters. The nasal cannula was also observed to be improperly applied on several occasions, and staff interviews indicated a lack of clarity regarding responsibility for verifying and adjusting oxygen settings. Another resident with diagnoses including pulmonary embolism and obstructive sleep apnea was observed using a CPAP machine without an active physician order for its use. The resident reported that her CPAP mask had never been cleaned since admission, and the mask was visibly soiled. Although there were orders for daily rinsing of the mask and weekly cleaning of the straps, staff interviews and documentation review revealed inconsistent cleaning practices and a lack of documentation for some days. Staff confirmed that a physician order was required for CPAP use, but none was present in the resident's record. Facility policy required review of physician orders for respiratory equipment and specified cleaning protocols. However, the observed practices did not align with these requirements, as evidenced by improper oxygen administration, lack of active orders for CPAP use, and inadequate cleaning of respiratory equipment. These failures were confirmed through staff interviews, record reviews, and direct observation.
Failure to Document and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that post-dialysis assessment and monitoring were completed and documented for a resident with end stage renal disease who was dependent on renal dialysis. Review of the resident's records showed there were no current physician's orders for monitoring and assessment upon return from dialysis, and no documentation of post-dialysis assessments, including vital signs, weight, and monitoring of the dialysis access site, after a certain date. Interviews with nursing staff confirmed that the expected practice was to obtain post-dialysis weight, vital signs, assess the dialysis access site, and document findings in a progress note and on the hemodialysis communication record form. However, these assessments and documentation were not completed as required. Further review of medication and treatment administration records revealed that orders for post-dialysis monitoring, including weight, vital signs, and assessment of the AV shunt site, had been discontinued and not reinstated, resulting in a lack of documentation for these parameters over a period of several months. The Director of Nursing acknowledged that the orders had been discontinued and that there was no evidence to show that post-dialysis assessments were completed during this time. This failure resulted in the potential for the resident to not achieve his highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Trauma-Informed Care and Individualized Interventions
Penalty
Summary
The facility failed to identify and address trauma-related triggers and develop individualized care plan interventions for two residents with significant trauma histories. For one resident, who had a complex medical and psychiatric background including bilateral below-knee amputations, schizoaffective disorder, substance use disorder, and a history of homelessness, sexual abuse, and family suicide, the care plan did not include trauma-informed interventions. Despite documentation of nightmares, anxiety, and a history of psychiatric hospitalizations, the social services director confirmed that no trauma assessment or trauma-specific care plan was in place, and staff were not informed of the resident's trauma history or potential triggers. Another resident, who experienced the traumatic loss of her home and pets in a house fire, was observed to be emotionally distressed and reported ongoing anxiety, depression, and stress related to her circumstances. Although her care plan addressed general psychiatric needs such as anxiety and depression, it did not include interventions specific to her trauma from the fire or the loss of her pets. The director of social services was unaware of any trauma-related care plan interventions for this resident and had not referred her to psychological services, despite a physician order for such a consult. The resident expressed that her emotional needs were unmet and that she had not received counseling or guidance regarding her living situation or trauma. Both cases demonstrated that the facility did not conduct adequate trauma assessments or develop trauma-informed care plans, despite clear evidence of traumatic experiences and ongoing emotional distress. The lack of individualized interventions and failure to inform staff of residents' trauma histories resulted in the potential for re-traumatization and unmet emotional needs, as staff were not equipped to recognize or mitigate trauma-related triggers during care.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute respiratory failure, generalized anxiety disorder, and major depressive disorder did not receive the necessary behavioral health care and services as required. The resident, who was cognitively intact and admitted for rehabilitation after being rescued from a house fire, reported that she was told she would receive emotional support upon admission but had not received any such services. She expressed a need for psychological support due to trauma from the fire and the loss of her belongings, and stated she previously had a counselor at home. Record review showed a physician's order for a psychological consult for anxiety and a care plan that included behavioral health consults and referrals to social services as needed. However, the Director of Social Services confirmed that no referral to psychological services or counseling had been made, citing the resident's short-term stay as the reason and stating she was unaware of the physician's order. As a result, the resident's psychological support service recommendations were not addressed and support services were not initiated as ordered.
Medication Error Rate Exceeds 5% Due to Insulin, Antidepressant, and Opioid Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration observations, as evidenced by errors involving two residents. For one resident, a registered nurse administered Lantus insulin from a pen that had been opened 38 days prior, exceeding the manufacturer’s guideline to discard after 28 days from opening. The nurse stated she followed the manufacturer’s expiration date rather than the open date, and the unit manager confirmed that while facility policy required discarding insulin pens 30 days after opening, this was not included in orientation education and was expected knowledge from nursing school. Another resident did not receive a scheduled dose of Wellbutrin 150 mg because the nurse reported the medication was not available and did not check the medication cart’s bottom drawer, where extra medications were stored. The medication administration record showed inconsistent documentation, with the medication marked as given on days when it may not have been administered. Additionally, the same resident was given Oxycodone 5 mg instead of the scheduled Morphine Sulfate ER, and the nurse documented that Morphine had been administered. The nurse later acknowledged the error and indicated she would correct the documentation. Facility policies required medications to be stored according to manufacturer recommendations and for staff to verify medication details, including expiration dates, prior to administration. Observations and interviews revealed lapses in following these policies, including inadequate checks for medication availability and improper administration and documentation of medications. These actions resulted in a medication error rate above the acceptable threshold.
Failure to Store and Manage Medications per Manufacturer and Facility Policy
Penalty
Summary
Facility staff failed to store and manage medications according to manufacturer instructions and facility policy. During medication administration, a registered nurse was observed using an insulin pen that had been opened 38 days prior, despite manufacturer guidelines stating it should be discarded 28 days after opening. Additional insulin pens on the medication cart were found to be opened for 51 and 33 days, both exceeding the facility's policy of discarding after 30 days. The unit manager confirmed that monitoring medication storage was assigned to the third shift, but acknowledged that all nurses should check expiration dates before administering medications. It was also noted that knowledge of insulin pen disposal was not included in the facility's orientation education. Further observations revealed an inhaler left out in a resident's room instead of being stored in the medication cart, and the medication cart itself was disorganized, with medication cards not alphabetized or separated by room. Another inhaler was found in the cart without an open date, making it impossible to determine if it was still within the 6-week usage period specified by the manufacturer. Review of facility policies confirmed that medications are to be stored per manufacturer recommendations and that medication carts should be kept clean and organized, with expiration dates checked prior to administration.
Failure to Implement Policy for Storage of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of foods brought in by family members and visitors for residents. During a kitchen tour, surveyors observed several food items in the resident refrigerator that were not labeled with opened or discard dates, including prepared macaroni salad, sweet tea, thickened lemon water, and ranch dressing. Additionally, prepackaged apples were found with a 'good through' date that had already passed. These observations indicated that the facility was not consistently ensuring that food items were properly labeled and discarded according to policy. In an interview, the Regional Registered Dietitian (RRD) acknowledged that the resident refrigerator was often in poor condition after weekends and that the Dietary Manager typically checked and discarded unlabeled or outdated items on Monday mornings. The facility's policy required all prepared foods brought in by family or visitors to be labeled with content and date, and to be consumed within three days. The lack of adherence to these procedures resulted in unknown discard dates and potentially hazardous foods being stored past their safe consumption period.
Failure to Implement Safety Measures Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of residents by not fully implementing a documented intervention of 1:1 supervision to prevent a fall for one resident and not ensuring an enabler bar was securely engaged before moving another resident in bed. Resident #102, who had Alzheimer's disease and a history of repeated falls, was supposed to be under 1:1 supervision due to her fall risk. However, the CNA assigned to her left her unattended to assist another resident, during which time Resident #102 attempted to walk without her walker and fell, resulting in a head injury. Resident #102's fall occurred after she was found on the floor by a nurse, having self-transferred without her walker. Despite being on 1:1 supervision, the CNA left her to address another resident's needs, leading to Resident #102 falling and sustaining a head injury. The resident was later found to have multiple hematomas and a large scalp hematoma, indicating a significant injury from the fall. Resident #103, who was cognitively intact, experienced a fall due to an improperly secured enabler bar. While receiving morning care, the resident rolled over and grabbed the bar, which was not locked in place, causing him to fall out of bed and sustain a skin tear on his right forearm. The CNA providing care at the time confirmed that the bar was not properly engaged, leading to the resident's fall.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address resident concerns regarding lengthy call light wait times, as documented in the Resident Council Minutes from meetings held on 7/18/24, 10/24/24, and 1/15/25. Despite repeated mentions of the issue, there was no indication of follow-up actions being taken to resolve the concerns. The minutes from these meetings highlighted ongoing dissatisfaction with call light response times, particularly during the 2nd and 3rd shifts and on weekends. Interviews with residents and staff further corroborated the issue. Resident #107 reported waiting up to an hour for call light responses, while Resident #106 experienced wait times of up to 30 minutes, especially during late-night and early-morning hours. Resident #101 noted that response times varied depending on staffing levels, with longer waits occurring when only one CNA was available. Staff members, including CNA J and CNA F, confirmed that residents had complained about long wait times, which were exacerbated by staffing shortages and breaks.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for two residents, resulting in dissatisfaction with meals. Resident #106, who has type 2 diabetes mellitus with diabetic nephropathy and is on long-term insulin use, reported that the food was hardly ever hot enough. Similarly, Resident #101, also diagnosed with type 2 diabetes mellitus, expressed that the food was not always hot, particularly during breakfast. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. Interviews with multiple staff members, including Certified Nurse Aides (CNAs) and a Registered Nurse (RN), confirmed that residents had complained about the food being served cold. The review of temperature logs showed that while there were no concerns documented for 2/16/25, there were no recorded temperatures for 2/17/25, and no documented temperatures for breakfast or lunch on 2/18/25. This lack of documentation and the consistent complaints from residents and staff highlight the facility's failure to ensure that food was served at a safe and appetizing temperature.
Failure to Provide Requested Food Items
Penalty
Summary
The facility failed to ensure that residents received the food items they requested, leading to dissatisfaction with meals and the potential for nutritional decline. Resident #106, who has type 2 diabetes mellitus and diabetic nephropathy, reported not receiving the correct breakfast items and not getting the substitutions she requested for items she did not eat, such as pork or shellfish. Similarly, Resident #101, also with type 2 diabetes mellitus, reported not receiving the cottage cheese she ordered, instead receiving a hot dog and coleslaw, which she did not request. Interviews with staff, including an LPN, CNAs, and an RN, revealed that residents frequently complained about not receiving their ordered meals. The LPN noted that there was often a delay in updating meal preferences on tray tickets, and sometimes preferences were not communicated to the kitchen. CNAs and the RN reported that residents sometimes did not receive requested beverages, nutritional supplements, or specific meal items, and when attempts were made to retrieve the correct items, they were told the kitchen did not have them. This issue led to residents ordering food from local restaurants instead of eating the meals provided by the facility.
Failure to Administer Oxygen Per Physician Order
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's order and professional standards of practice. The resident, who had severe cognitive impairment and multiple diagnoses including obstructive lung disease and heart failure, was observed multiple times without the prescribed continuous oxygen therapy. The oxygen concentrator in the resident's room was found turned off, and the oxygen tubing was improperly stored, not in the designated storage bag, which could lead to cross-contamination. Interviews with staff revealed a lack of awareness and adherence to the resident's oxygen orders. A Licensed Practical Nurse initially stated that the resident did not have orders for oxygen, but later confirmed the resident was on oxygen after reviewing the orders. A Certified Nursing Assistant was observed adjusting the oxygen concentrator to the correct flow rate after noticing it was not set properly. The facility's policy on oxygen administration emphasized the need for proper storage of oxygen delivery devices and adherence to physician orders, which was not followed in this case.
Sanitary Conditions and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all 87 residents. During an initial kitchen tour, it was observed that the reach-in refrigerator had an outside temperature gauge reading of 53 degrees and an inside temperature gauge reading of 46 degrees, both above the recommended 41 degrees Fahrenheit. Despite these high temperatures, the refrigerator remained packed with food. The Maintenance Director attempted to fix the issue by chipping away ice from the fan and using a flame to remove ice, which further increased the temperature. The Dietary Director instructed staff to avoid opening the refrigerator to prevent further temperature increases and later decided to discard all perishable food items. Further observations revealed that the refrigerator was eventually cleared of most food items, except for some condiments and tomatoes, which were later removed. The Nursing Home Administrator was initially unaware of the temperature issue. A follow-up tour found that the three-door continental refrigeration unit was struggling to maintain temperature, and a vendor was scheduled to assess it. Additionally, a spray bottle containing an unidentified green solution was found in the kitchen, and shredded lettuce was improperly stored behind raw pork chops, posing a risk of cross-contamination. These findings indicate a failure to adhere to safe food handling practices as outlined in the FDA Food Code.
Hot Water Temperature Exceeds Safe Levels in B Hall
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F in the B hall, resulting in an increased risk of injury among residents. During a tour of the B hall shower room, the hot water was measured at 127°F using a rapid read digital thermometer. Similarly, the hot water in the B hall soiled utility room sink reached 128°F. The Maintenance Director (MD) confirmed that each hall has its own hot water system, and the outgoing hot water to the B hall domestic fixtures was recorded at 128°F without any mixing valves to temper the water. The Maintenance Director was unsure if the temperatures varied throughout the day, as the Maintenance staff typically checks the temperatures in the morning and does not track fluctuations during the day as demand changes.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices for several residents, leading to potential risks of infection and cross-contamination. Observations revealed that Enhanced Barrier Precautions (EBP) were not consistently implemented for residents with indwelling medical devices, such as catheters and feeding tubes. For instance, residents with catheters did not have EBP signs posted outside their rooms, and staff did not consistently use personal protective equipment (PPE) when providing care. Additionally, CPAP machines and tubing were not properly cleaned or stored, increasing the risk of infection. In several instances, staff failed to adhere to proper wound care protocols. During wound dressing changes, supplies were placed directly on bed linens without barriers, and contaminated items were not disposed of properly. Staff did not change gloves between tasks, and contaminated scissors were used repeatedly without cleaning. These practices were observed during wound care for residents with pressure ulcers and other wounds, further compromising infection control measures. The facility also demonstrated lapses in maintaining cleanliness of medical equipment and resident areas. Nebulizer machines, IV poles, and feeding pumps were observed with splatters of substances and dust, indicating inadequate cleaning. Feeding tube lines were found on the floor without end caps, posing a risk of contamination. Wheelchairs and other resident equipment were not properly maintained, with non-cleanable surfaces and debris present. These deficiencies highlight a systemic issue with infection control practices within the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, specifically involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal threats and physical aggression towards staff and other residents. On one occasion, Resident #15 admitted to slapping another resident and expressed a willingness to repeat such actions. Family members were aware of Resident #15's violent behavior, which had occurred multiple times in the past. Resident #40, also cognitively impaired with a BIMS score of 12, was involved in a physical altercation with Resident #15. An incident report detailed that Resident #15 punched Resident #40 in the face after a verbal exchange, where Resident #40 allegedly insulted Resident #15. Staff attempted to intervene but were unable to prevent the physical altercation. Observations noted that Resident #15 continued to exhibit loud and inappropriate behavior, including making sexually inappropriate remarks, without adequate supervision. Interviews with staff revealed ongoing concerns about the interactions between Resident #15 and Resident #40, as both residents were known to treat staff poorly. Despite attempts to monitor and separate the residents, they continued to have verbal and physical altercations. The Nursing Home Administrator was unaware of a recent verbal altercation between the two residents, indicating a lack of effective communication and supervision within the facility.
Failure to Prevent Resident Abuse During Investigation
Penalty
Summary
The facility failed to implement interventions to prevent further abuse during an ongoing investigation involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal aggression and physical altercations with other residents. Despite these behaviors, the facility did not adequately monitor Resident #15, as evidenced by an incident where he punched Resident #40 in the face after a verbal altercation. The care plan for Resident #15 included monitoring when he was around other residents, but this intervention was not effectively implemented. Resident #40, also cognitively impaired with a BIMS score of 12, reported being easily irritated by Resident #15. On one occasion, Resident #15 was left unsupervised in the hallway, where he engaged in loud and inappropriate behavior, leading to another altercation with Resident #40. Staff interviews revealed that the residents frequently encountered each other, exacerbating tensions. Despite the ongoing investigation and previous incidents, the facility did not ensure adequate supervision or separation of the residents to prevent further conflicts.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide the required transfer or discharge notice to two residents, R43 and R30, when they were transferred to the hospital. R43, who was cognitively intact with a BIMS score of 15/15, was transferred to the hospital on 1/27/24 due to an emergency but did not receive the necessary transfer documentation. The Nursing Home Administrator confirmed the absence of the emergent transfer notification for R43. Similarly, R30, who also had a high BIMS score indicating cognitive intactness, was discharged to the hospital due to congestion and shortness of breath but did not receive a written notice of transfer. The medical records for R30 lacked evidence of the required transfer notice documentation. Interviews with facility staff revealed a lack of adherence to the policy regarding transfer/discharge notices. RN AA admitted that she does not send written transfer notices with residents when they are discharged to the hospital. The Director of Nursing, DON B, acknowledged that the transfer/discharge notice should be included in the packet sent to the hospital and recorded in the electronic medical record, but was unsure if this was being consistently done. The facility's policy requires that transfer notices be provided as soon as practicable, but this was not followed in the cases of R43 and R30.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to notify two residents of the bed hold policy in writing upon their transfer to a hospital, as required by the facility's policy. Resident #30, who was cognitively intact, was discharged to the hospital due to congestion and shortness of breath but did not receive a written bed hold policy notice. During interviews, both the resident and the Director of Nursing confirmed the absence of such documentation in the resident's electronic medical record. The Registered Nurse also admitted that she does not provide a written bed hold policy to residents upon hospital discharge. Similarly, Resident #43, who was also cognitively intact, was transferred to the hospital and did not receive a written bed hold policy notice. The facility's records and an email from the Nursing Home Administrator confirmed the lack of documentation regarding the bed hold policy for this resident. The facility's policy, revised in 2022, mandates that residents or their representatives receive written notice of the bed hold policy at the time of transfer, which was not adhered to in these cases.
Inconsistent IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, specifically concerning the administration of IV antibiotics to a resident. The resident, who was admitted with severe sepsis and cellulitis, was prescribed Cefazolin to be administered intravenously three times a day. However, the medication was consistently administered outside the physician-ordered parameters. Observations and interviews revealed that the medication was given late multiple times, and the resident expressed uncertainty about whether the medication was administered at all on some occasions. The Medication Administration Record showed that all 17 doses were administered outside the recommended timeframe. Interviews with nursing staff and the Director of Nursing highlighted a lack of clarity and consistency in administering the medication. A registered nurse admitted to administering the medication late and not labeling the IV bag or tubing. The Director of Nursing mentioned a permissible one-hour window for administration, but the medication was still given outside this timeframe. A nurse practitioner clarified that the medication should be administered every eight hours to maintain consistent blood levels, but this was not reflected in the orders or practice. The lack of specific administration times in the updated order further contributed to the inconsistency in medication administration.
Failure to Provide Necessary ADL Assistance and Equipment
Penalty
Summary
The facility failed to identify and address the need for increased assistance with Activities of Daily Living (ADL) for Resident #67, who was dependent on staff for assistance due to pyogenic arthritis. Despite being cognitively intact, Resident #67 reported worsening knee pain and an inability to walk safely with a walker, which was not addressed by the facility. The resident communicated his need for a wheelchair to the nursing staff, doctor, and therapy department, but no action was taken to provide one. This lack of response resulted in the resident struggling with mobility, experiencing incontinence, and being unable to maintain personal hygiene. Interviews with facility staff revealed a lack of awareness and communication regarding Resident #67's increased needs. The Certified Occupational Therapy Assistant (COTA) assumed the resident had informed the nurses, while the Registered Nurse (RN) and Unit Manager (UM) were unaware of the resident's need for a wheelchair. The resident's family member also reported the resident's inability to walk and the need for assistance, which was not addressed by the facility. The resident's care plan and progress notes indicated a high risk for falling and ongoing knee pain, yet the necessary interventions were not implemented.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the worsening of pressure ulcers for Resident #15, who was cognitively impaired and had a history of heart and respiratory failure. The resident had a chronic stage 4 surgical ulcer on the left hip and an unstageable ulcer on the left heel. The care plan required daily dressing changes, but observations and interviews revealed that the dressings were not changed as frequently as ordered. The wound dressings were dated several days prior to the observation, indicating a lack of adherence to the prescribed treatment schedule. Interviews with the resident and a family member highlighted dissatisfaction with the wound care, noting infrequent dressing changes and a foul odor suggesting infection. The wound nurse and floor nurses were responsible for the wound care, but there was a lack of documentation and accountability for ensuring daily dressing changes. The treatment administration record inaccurately documented dressing changes, and there were no physician orders for wound care on specific dates, further indicating a lapse in care. Observations of the wounds showed signs of deterioration, including black crusting and maceration, which were not adequately addressed in the resident's records.
Failure to Maintain Dialysis Communication for a Resident
Penalty
Summary
The facility failed to maintain proper communication and documentation regarding dialysis treatments for a resident with end-stage renal disease who was dependent on dialysis. The resident, who was cognitively intact, had not had any dialysis communication forms uploaded to their medical record since February 17, 2024. Interviews with facility staff revealed that the dialysis communication binder, which was supposed to accompany the resident to and from the dialysis center, was missing, and no communication forms had been received for the past three months. Staff members, including a registered nurse, medical records personnel, and a licensed practical nurse, acknowledged the absence of the communication forms and the lack of documentation in the resident's medical record. The Director of Nursing confirmed that if the binder was missing, no communication was occurring between the facility and the dialysis center. The facility was unable to provide any documentation of communication regarding the resident's dialysis treatments between February 18, 2024, and the date of the survey exit.
Medication Administration Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 16% error rate during the survey. This deficiency was observed in two residents. For Resident #7, there were multiple medication administration failures. The resident had active physician orders for Aripiprazole, Calcitriol, and Nepro, all of which were not administered on the day of observation due to unavailability. The Registered Nurse (RN) reported that the Aripiprazole and Calcitriol had been ordered but were not yet available, and the Nepro supplement was missing from the supply closet. These omissions were documented in the Medication Administration Record (MAR) as not given due to being unavailable. For Resident #340, a medication administration error occurred when the RN administered a lower dose of Fexofenadine than prescribed. The resident was ordered to receive 180 mg of Fexofenadine, but only 60 mg was initially given. Upon realizing the error, the RN acknowledged the mistake and planned to administer additional pills to meet the prescribed dose. These incidents highlight the facility's failure to ensure the availability and correct administration of medications, contributing to the elevated medication error rate.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure proper storage and administration of medications, including controlled substances, for two residents. For one resident, a registered nurse left a medication cup with various pills, including a controlled substance, on the bedside table without observing the resident taking them. The resident expressed that this was not a usual practice and was unfamiliar with the nurse who left the medications. The resident's records did not indicate any orders or assessments for self-administration of medications, and the care plan lacked a focus on self-administration. Additionally, a self-administer medications evaluation had not been conducted for this resident. For another resident, a registered nurse left a medication cup containing two controlled substances on the bedside table while performing wound care, leaving the room multiple times for more than three minutes with the door closed and privacy curtain pulled. This resident was cognitively intact according to their BIMS score, but there were no orders for self-administration of medications, and the care plan did not include a focus on self-administration. A self-administer medications evaluation was also not present in the resident's medical chart. The Director of Nursing confirmed that no residents in the facility were authorized to self-administer medications, and medications should not be left at the bedside.
Inaccurate Documentation and Delayed Wound Care
Penalty
Summary
The facility failed to ensure accurate documentation and timely care for a resident with pressure ulcers, leading to potential issues in follow-up care and assessment. A family member reported that the resident's wound dressings were not changed as frequently as required, which they believed contributed to the lack of healing. During an observation, it was noted that the dressings on the resident's wounds were dated several days prior, indicating that the wound care had not been performed as scheduled. Interviews with staff revealed inconsistencies in the documentation and execution of wound care orders. The wound nurse could not confirm if care was provided on specific dates, and the Treatment Administration Record inaccurately reflected that wound care was completed on days when it was not. The resident's care plan required daily dressing changes, but there were no orders for care on certain dates, and the documentation did not match the observed condition of the dressings.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, resulting in unclean rooms and bathrooms. Resident #33, who has diagnoses including unspecified dementia and anxiety disorder, was found to have a room with a persistent odor of urine, sticky floors, and flying insects. Observations over several days noted liquid on the floor, dirt and debris along the baseboards, and pieces of food on the floor. Family members expressed concerns about the cleanliness and the presence of urine on the floor. Resident #83, diagnosed with bladder-neck obstruction and a cognitive communication deficit, also experienced similar issues. His room and bathroom were observed to have an odor of urine, sticky floors, and flying insects. The resident was seen emptying his urinary drainage bag, which led to liquid on the floor. The bathroom was noted to be dirty with food and liquid that appeared to be urine. Interviews revealed that the resident was not able to properly manage his urinary drainage bag, leading to leaks and further contributing to the unclean environment. The District Housekeeping Manager acknowledged the issues, noting that the resident's room was a high-focus area for cleaning due to frequent problems with cleanliness and odors. The Interim Nursing Home Administrator was aware of the housekeeping issues and was working on resolving them. Despite daily cleaning assignments, the facility's failure to maintain a clean environment for these residents was evident through repeated observations and family member reports.
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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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