Niles Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Michigan.
- Location
- 911 S 3rd St, Niles, Michigan 49120
- CMS Provider Number
- 235361
- Inspections on file
- 32
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 31 (2 serious)
Citation history
Health deficiencies cited at Niles Care Center, Llc during CMS and state inspections, most recent first.
A cognitively intact resident reported that the food was so poor she ordered the same limited meal every night and had to buy her own preferred items, despite having discussed her preferences with the Dietary Supervisor. Two other cognitively intact residents stated that the kitchen frequently ran out of commonly used items such as brown sugar, butter, bananas, peach cups, pudding, and even hot dogs and hamburgers that were listed on the always available menu, especially from the middle to the end of the month. Dietary staff and the RD confirmed that corporate adjusted weekly food orders to stay within budget and that some items had been removed or had run out, while the NHA reported being unaware of residents’ concerns about food shortages.
A resident with severe chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and medication from the pharmacy. Despite staff awareness of the issue and the resident's ongoing severe pain, the medication was not administered until after intervention by the ombudsman. Documentation and staff interviews confirmed lapses in communication and medication management, resulting in unmet pain management needs.
A resident with chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and lack of timely follow-up by nursing staff and facility leadership. The resident experienced severe, uncontrolled pain during this period, and staff interviews revealed gaps in communication and awareness regarding the medication issue.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental hazards and insufficient staff monitoring.
The facility failed to adhere to food safety and sanitation standards, as observed during a survey. Cooked roast beef was improperly cooled, and various food items lacked proper date markings. Cleanliness issues were noted with kitchen equipment, and the dish machine did not reach required temperatures. A staff member was observed handling food with bare hands, violating contamination prevention guidelines.
The facility failed to implement proper infection control practices, as observed in multiple instances where staff did not adhere to PPE protocols for residents on contact precautions. The facility also lacked an ongoing infection control surveillance program, with no tracking of employee illnesses and no recent audits of hand hygiene or PPE use. Additionally, there was no active plan to manage the risk of legionella and other pathogens in the facility's water systems.
The facility failed to document and offer COVID-19 vaccination to its staff, specifically a CNA who was last vaccinated in 2021. The DON confirmed that the facility had not offered the vaccine in 2024 and had not tracked staff immunization status or provided education, increasing the risk of COVID-19 infections among residents.
The facility exhibited multiple environmental deficiencies, including structural damage, improper storage, and unsanitary conditions. Observations revealed holes in walls, moisture damage, stained and improperly stored items, non-operational equipment, and significant wear and tear in common areas. These issues increased the potential for contamination and decreased resident satisfaction.
A long-term care facility reported a 20% medication error rate involving four residents. Errors included improper injection sites, late medication administration, missed doses, and crushing of delayed-release medication. LPNs administered injections incorrectly, misunderstood timing protocols, failed to use backup medication supplies, and crushed medication against prescription instructions.
The facility's ineffective pest control program resulted in an ant infestation in resident rooms, hallways, and visitor restrooms. Despite having a monthly pest control service, the Maintenance Assistant did not treat the building for ants between visits. The Nursing Home Administrator was unaware of the issue, which persisted for several days, contributing to potential food infestation and resident discomfort.
A resident with a gastrostomy tube was not receiving the prescribed enteral feeding due to improper management by nursing staff. The feeding pump was often off during scheduled times, and the total volume of formula was not documented, leading to insufficient nutritional intake. The facility's staff failed to adhere to the prescribed feeding schedule and volume, as confirmed by the RD and DON.
Three residents in an LTC facility did not receive adequate assistance with ADLs, leading to dissatisfaction and hygiene concerns. A resident expressed dissatisfaction with the frequency of showers, while another appeared disheveled with long, dirty fingernails due to missed shower opportunities. A third resident was observed with soiled fingernails and expressed frustration over inadequate assistance with personal hygiene.
A resident with a G-tube was not administered enteral feeding as ordered, leading to potential health risks. Observations showed the feeding pump was often off, and the tubing was not connected. LPNs reported inconsistencies in feeding times, and the MAR lacked documentation of the total formula volume. The DON confirmed the resident did not receive the full prescribed amount of formula.
A facility failed to conduct gradual dose reductions (GDRs) for a resident on Duloxetine for major depressive disorder. The resident's dosage remained unchanged for over a year, and no attempts at GDR were made in 2024. The facility lacked documentation of GDR or physician rationale against it.
The facility failed to prevent scalding hazards by allowing hot water temperatures to exceed safe limits and did not consistently monitor these temperatures. Additionally, a resident at high risk for elopement exited the facility unnoticed due to unsecured and unalarmed doors, despite having a history of wandering behavior. The resident's wander guard was not properly checked or ordered after readmission, contributing to the incident.
A resident with Alzheimer's was physically abused by another resident with a history of aggressive behavior in the dining room. Despite interventions in place, the aggressive resident flipped the other resident's wheelchair, leading to threats and police involvement. The facility's abuse prevention measures were insufficient to prevent this incident.
A facility failed to report a suspected abuse incident involving a resident with schizophrenia, anxiety, depression, dementia, and aphasia to Law Enforcement. The incident, where a CNA allegedly held the resident's breast, was reported internally but not to authorities, violating the facility's policy and federal requirements.
A facility failed to address a resident's skin integrity in the baseline care plan, despite the resident's history of skin issues and a rash noted upon admission. The care plan did not include skin integrity, and this omission was confirmed by the DON. The facility's policy requires addressing such concerns within 48 hours of admission.
A resident admitted for a respite stay under Hospice care developed a yeast infection under her breast due to the facility's failure to address a pre-existing rash noted upon admission. The rash was documented but not followed up on, leading to a lapse in care continuity. Facility staff were unaware of the condition, resulting in the infection being discovered by a Hospice LPN four days later.
A resident with cognitive impairment reported being left in a soiled brief for over six hours and experiencing long wait times for assistance. The facility's investigation into the grievance was inadequate, with only verbal staff education conducted without documentation, failing to meet the grievance policy requirements.
A resident with moderate cognitive impairment alleged rough handling by a CNA and an LPN, which was not reported immediately to the NHA or law enforcement, violating facility policy. The NHA admitted to only reporting significant incidents, leading to an incomplete investigation. Additionally, a neglect concern was raised by the resident, which was not reported to the state agency, indicating systemic issues in handling such allegations.
Failure to Honor Food Preferences and Maintain Adequate Food Supply
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and maintain adequate food supplies as required by policy. One cognitively intact resident, Resident #37, reported that the food was so poor that she ordered the same dinner every night—two hamburger patties without a bun and dessert—and that she had to purchase her own English muffins because the kitchen would not obtain them for her. She also stated she preferred tomatoes on salads and more vegetables and had previously discussed her preferences with the Dietary Supervisor but remained dissatisfied. Review of the facility’s Food Preference Policy indicated that if a resident is unhappy with their diet, staff will create a care plan that the resident is satisfied with and that the Food Services Department will offer a variety of foods at each scheduled meal. Two other cognitively intact residents, Resident #16 and Resident #29, reported that the kitchen frequently ran out of various food items, particularly from the middle to the end of the month. Resident #16 stated the kitchen ran out of brown sugar, butter, bananas, peach cups, and that hot dogs and hamburgers—listed on the always available menu—had been unavailable for a week, and that food served was often disliked and condiments were not available. Resident #29 similarly reported that hot dogs, hamburgers, pudding, and bananas ran out often, especially mid- to late month. The Dietary Supervisor and Registered Dietitian confirmed that food orders were placed weekly, then adjusted by corporate to stay within budget, and acknowledged that brown sugar had been removed from orders and that bananas had run out in the past, though alternative fruits were available. The Nursing Home Administrator stated she was not aware that residents reported food running out mid- to late month.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A resident with chronic pain, obesity, depression, and severe osteoarthritis of the left hip was admitted to the facility and required physician-ordered pain management, including Norco (hydrocodone-acetaminophen). Despite having clear physician orders for Norco, the resident did not receive the medication for 11 consecutive days. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as Tylenol and Ibuprofen were not effective. The resident indicated that staff were aware of the missing Norco and repeatedly informed him that the pharmacy had not shipped the medication yet. Review of the resident's medical records and medication administration records confirmed that Norco was not administered from the start date of the order through the period in question. Progress notes documented ongoing issues with obtaining the medication, including references to awaiting supply, missing scripts, and delays attributed to the Thanksgiving holiday. Staff interviews revealed that delays in receiving medications from the pharmacy were not uncommon, and several nurses believed that facility management was aware of the issue. However, both the DON and NHA stated they were not aware of the resident missing Norco until the ombudsman intervened. Further interviews with facility leadership and the prescribing physician highlighted communication breakdowns and procedural lapses. The DON reported that the pharmacy did not receive the necessary script and that there was difficulty getting the physician to provide it due to the holiday. The physician acknowledged he could have sent the script electronically but did not recall the specifics of the situation. The facility's policy required providing care and services according to established guidelines, but the resident's pain management needs were not met due to these failures in medication procurement and communication.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to follow professional standards of practice by not ensuring timely follow-up on a physician-ordered pain medication for a resident with chronic pain, osteoarthritis, obesity, and depression. The resident was admitted with significant pain issues and had a physician order for Norco (hydrocodone-acetaminophen) to manage pain. Despite the order, the resident did not receive the prescribed Norco for at least 11 days, missing 11 doses, due to delays in obtaining the medication from the pharmacy and issues with obtaining the necessary prescription script. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as ibuprofen and acetaminophen were not effective. Nursing staff were aware that the Norco had not arrived and communicated this to the resident, but there was no documented escalation or effective resolution of the issue. Progress notes repeatedly indicated that the medication was "awaiting supply" or that the pharmacy had not received the script, yet there was no evidence of timely follow-up with the physician or pharmacy to resolve the delay. Interviews with nursing staff and facility leadership revealed a lack of awareness and communication regarding the ongoing medication issue. The DON and NHA were not aware of the missed doses until informed by an ombudsman. The physician and nurse practitioner involved were also not fully aware of the extent of the delay, and the physician did not review the medication administration record during a subsequent visit. Facility policy required providing care and services according to established practice guidelines, but this was not followed in ensuring the resident received the ordered pain medication.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a survey. In the kitchen's walk-in cooler, containers of cooked roast beef were found with condensation and moisture, and their temperatures were not adequately cooled to the required standards. The Director of Housekeeping, filling in for the Dietary Manager, was unsure about the cooling logs for these items. Additionally, various food items in the cooler and nourishment room were improperly dated or lacked date markings, violating the FDA Food Code requirements for date marking and disposition of ready-to-eat foods. The survey also revealed several cleanliness and maintenance issues in the kitchen. Mechanical scoops and the coffee spout were found with dried food debris and coffee accumulation, respectively. The microwave had crusted debris, and the ventilation filters on the cook line had excess grease accumulation. The preparation sink was not properly set up, allowing water to dispense onto the floor, and the chemical closet's setup put undue pressure on the mop sink faucet's vacuum breaker. Furthermore, the dish machine was not reaching the required temperatures for washing and rinsing, and an open gallon of soy sauce was improperly stored in the dry storage room. During meal service, a staff member was observed handling baked potatoes with bare hands, deviating from the initial use of utensils and gloves. This practice violated the FDA Food Code's guidelines for preventing contamination from hands. These deficiencies collectively indicate a failure to adhere to food safety and sanitation standards, potentially leading to foodborne illnesses among residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices during resident care, as evidenced by multiple observations and interviews. For instance, a housekeeping aide was observed not wearing personal protective equipment (PPE) while handling trash and cleaning surfaces in a resident's room who was on contact precautions due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. This aide believed that the contact precautions did not apply to housekeeping staff, a misunderstanding that was echoed by the Director of Housekeeping, despite the Director of Nursing's (DON) assertion that all staff should adhere to these precautions. Additionally, the facility did not maintain an ongoing infection control surveillance program. The Director of Nursing/Infection Preventionist (DON/IP) admitted that there was no tracking of employee illnesses, which could potentially lead to the spread of illness among residents. Furthermore, the facility had not conducted hand hygiene or PPE audits since May 2024, increasing the risk of cross-contamination between residents and staff. The facility also lacked an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Observations revealed multiple stagnant water lines, and interviews with maintenance and housekeeping staff indicated a lack of awareness and documentation regarding a water management plan. The facility's policy on water systems and legionella risk prevention was not actively implemented, as there was no evidence of a completed risk assessment or a building-specific list of areas at risk for legionella growth.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status, education, and offering for its staff, specifically for a Certified Nursing Assistant (CNA) identified as DD. The CNA was last vaccinated on November 24, 2021, and there was no documentation of any subsequent offering or education regarding the COVID-19 vaccine. During an interview, the Director of Nursing (DON), who also serves as the Infection Preventionist, confirmed that the facility had not offered the COVID-19 vaccination to staff in 2024 and had not tracked their immunization status or provided education on the matter. This lack of documentation and action increased the risk of COVID-19 infections among residents.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by multiple observations during a survey. In the nourishment room, a large hole under the sink exposed the back wall, presenting a potential entry point for pests, along with moisture damage and a black staining-like substance. An empty resident room was found with a large brown splash stain and bubbling walls, indicating possible water damage. The 200 hall bath had towels and washcloths improperly stored, and a shower chair with dried brown stains. The 200 Hall Soiled Utility room had brown-tinted water from the faucet, a slow leak, and a musty odor from moisture-damaged cabinetry. The 300 Hall Soiled Utility room had a leaking valve, incomplete flushing of the hopper, and a non-operational sink with a disconnected wastewater line and a large hole in the cabinetry. Further deficiencies were noted in the 200 hall janitor's closet, where a chemical pre-dispense system was improperly set up, risking damage to the faucet's vacuum breaker. The boiler room had one non-operational water heater, though the maintenance staff believed they could meet hot water demand. The 500 hall bath had missing floor tiles, debris under shower beds, and an unused tub with dirt and debris. The lobby area had significant drywall damage, and the dining room had bubbled wallpaper, rusted floor vents, and built-up debris around door frames. These conditions collectively increased the potential for contamination and decreased resident satisfaction with their living environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a total error rate of 20% among four residents. For Resident #15, the error involved improper administration of subcutaneous injections. The LPN administered insulin aspart and Mounjaro injections into the deltoid muscle, which is not an acceptable location for subcutaneous injections according to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). This error was confirmed through interviews with the LPNs and the DON, who clarified that subcutaneous injections should be given in fatty areas such as the back of the arms, abdomen, and outer thighs. Resident #25 experienced a late administration of baclofen, which was ordered to be given at 3:00 PM but was administered at 4:28 PM. The LPN believed that medications could be given within an hour before or after the scheduled time, but the DON confirmed that the administration was late. This discrepancy in understanding the timing of medication administration contributed to the error. For Resident #30, the error involved a missed dose of gabapentin due to its unavailability in the medication cart. The LPN did not retrieve the medication from the facility's backup medication box, despite its availability, citing a lack of time. Resident #43's error involved the crushing of acamprosate, a delayed-release medication, which should not be crushed as it alters absorption. The LPN crushed the medication despite the prescription label indicating 'Do Not Crush,' and this was confirmed by the pharmacist and the DON.
Ineffective Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live ants in various areas, including resident rooms, hallways, and visitor restrooms. Observations on multiple occasions revealed live ants on the bathroom floor of a resident's room, in the hallway outside the room, and in the visitor restroom. Open food containers with resident food were also found stored on the floor, which could contribute to the ant infestation. Interviews with housekeeping aides confirmed the presence of ants throughout the building, particularly around food crumbs in resident areas. Despite having a pest control service that visits monthly, the Maintenance Assistant admitted to not chemically treating the building for ants between visits. The Nursing Home Administrator was unaware of the ant issue in the visitor bathroom, despite staff using the facility and the problem persisting for several days. The lack of timely intervention and awareness of the pest issue by the facility's staff contributed to the ongoing presence of ants, posing a potential risk for food infestation and resident discomfort.
Failure to Maintain Professional Standards in Enteral Feeding Administration
Penalty
Summary
The facility failed to maintain professional nursing standards during the administration of enteral feeding for a resident with dysphagia and a gastrostomy tube. The resident was prescribed an NPO diet with enteral feeding of Vital 1.5 formula at 75cc/hr for 20 hours, starting at 3:00 PM and ending at 11:00 AM. However, observations revealed that the feeding pump was often powered off during the prescribed feeding times. Interviews with nursing staff indicated discrepancies in the start times of the feeding, with one LPN stating the feeding began at 6:00 PM instead of the ordered 3:00 PM. Additionally, the total volume of formula administered was not documented in the Medication Administration Record (MAR), and the resident did not receive the full prescribed amount of 1500 ml daily. The Registered Dietitian and Director of Nursing both confirmed the expectation that the feeding should start at 3:00 PM and end at 11:00 AM, with a total of 1500 ml administered. However, observations showed that the feeding pump was alarming due to an empty formula bottle and air bubbles in the tubing, indicating that the feeding was not properly managed. The LPNs involved did not hang a second bottle of formula, resulting in the resident not receiving the full nutritional intake as ordered. The MAR lacked documentation of actual start and stop times, further contributing to the deficiency in care.
Inadequate Assistance with ADLs and Hygiene Concerns
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to dissatisfaction with care and hygiene concerns. Resident #46, who was cognitively intact, expressed dissatisfaction with the frequency of showers received, stating he had only a couple of showers since admission, despite a preference for two showers a week. The facility's records confirmed that Resident #46 did not receive the scheduled showers consistently, with only three showers documented over a period of several weeks. Resident #27, who was moderately cognitively impaired, required supervision or touching assistance for bathing. Observations and family reports indicated that Resident #27 appeared disheveled with long, dirty fingernails, suggesting inadequate assistance with personal hygiene. The facility's records showed that Resident #27 was offered showers on only 16 out of 27 scheduled opportunities, indicating a failure to adhere to the shower schedule. Resident #38, who was cognitively intact but required maximal assistance for personal hygiene, was observed with soiled fingernails on multiple occasions. The resident expressed frustration and embarrassment over the dirty appearance of her nails and reported needing more assistance from staff. Family members also noted the resident's dirty fingernails during visits, highlighting a lack of adequate care in maintaining personal hygiene.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that enteral feeding was administered as ordered for a resident with a gastrostomy tube, resulting in the potential for weight loss, dehydration, and overall deterioration of wellbeing. The resident, who had a history of dysphagia following a stroke, was observed multiple times with her feeding pump powered off and the feeding tubing not connected to her G-tube, despite orders for continuous feeding from 3:00 PM to 11:00 AM at a rate of 75cc/hr. Interviews with nursing staff revealed inconsistencies in the administration of the resident's tube feeding. One LPN reported turning off the feeding an hour earlier than ordered, while another LPN admitted to starting the feeding later than the prescribed time. The Medication Administration Record lacked documentation of the total volume of formula administered, and observations confirmed that the resident did not receive the full prescribed amount of formula. The Director of Nursing confirmed that the resident should receive a total of 1500 ml of formula daily, which was not achieved due to the failure to hang a second bottle of formula. The Registered Dietitian also emphasized the importance of adhering to the feeding schedule to ensure the resident received the necessary nutrition. The lack of adherence to the prescribed feeding schedule and documentation requirements led to the deficiency identified by the surveyors.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) for the ongoing use of psychotropic medications were completed for a resident reviewed for unnecessary medications. The resident had a diagnosis of major depressive disorder and was prescribed Duloxetine 60 mg to be administered enterally once a day. The Director of Nursing (DON) reported that the resident's dosage of Duloxetine had remained unchanged for over a year, and there had been no attempt at a gradual dose reduction during 2024. Additionally, the facility was unable to provide any documentation of a gradual dose reduction or a physician's rationale against it for the resident's Duloxetine prescription.
Failure to Prevent Scalding Hazards and Resident Elopement
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing hot water temperatures to exceed 120 degrees Fahrenheit in resident rooms and shower areas. During an inspection, it was observed that the water temperatures in several rooms and shower areas were above the recommended limit, with some reaching as high as 125.4 degrees Fahrenheit. The facility's maintenance director acknowledged the issue, citing difficulties in maintaining appropriate temperatures due to only one functioning boiler. Additionally, the facility's water temperature logs for August and October were missing, indicating a lack of consistent monitoring. The facility also failed to prevent an elopement incident involving a resident identified as high risk for elopement due to cognitive impairment and wandering behavior. The resident managed to exit the facility without staff knowledge and was found outside by a CNA. The therapy exit door, through which the resident exited, was not alarmed or locked at the time, allowing the resident to leave unnoticed. Interviews with staff revealed that the door was not secured after the last therapy session, and the alarm system was not functioning properly at the nurse's station. The resident involved in the elopement had a history of exit-seeking behavior and was supposed to have a wander guard in place. However, there was a lapse in ensuring the wander guard was checked and functioning, as there were no orders for its use after the resident's readmission to the facility. The facility's policies on monitoring residents at risk of elopement and ensuring door alarms were not adequately followed, contributing to the resident's ability to leave the premises undetected.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, resulting in physical abuse. Resident #104, a male with Alzheimer's disease and cognitive deficits, was physically abused by Resident #103, who has a history of dementia, anxiety, and aggressive behavior. The incident occurred in the dining room where Resident #104 was approached by Resident #103 and flipped over in his chair, leading to threats exchanged between the two residents. Resident #103 has a documented history of maladaptive behavioral symptoms, including verbal altercations and aggressive behavior towards other residents and staff. Prior to the incident, Resident #103 had been involved in a similar altercation where he attempted to swing a walker at another resident. Despite these behaviors, the care plan for Resident #103 included interventions such as behavior management techniques and stress management, but these measures were insufficient to prevent the incident. The incident was witnessed by staff and a visitor, who reported that Resident #104 was rearranging tables when Resident #103 became agitated and flipped him over. The facility's policy on abuse prevention defines abuse as the willful infliction of injury or intimidation, which was not adequately prevented in this case. The failure to effectively manage Resident #103's behavior and protect Resident #104 from harm constitutes a deficiency in the facility's abuse prevention measures.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a resident with multiple diagnoses including schizophrenia, anxiety, depression, dementia, and aphasia. The incident involved a Certified Nursing Assistant (CNA) allegedly holding the resident's breast while changing the resident's brief. This incident was reported internally to the charge nurse and Nursing Home Administrator (NHA) but was not reported to Law Enforcement as required by the facility's Abuse Prevention Program Policy and Section 1150B of the Social Security Act. Interviews with the current NHA, Director of Nursing (DON), and another NHA revealed uncertainty and acknowledgment that the incident should have been reported to Law Enforcement. The facility's policy clearly states that such incidents should be reported immediately to Law Enforcement, but this procedure was not followed. The lack of reporting to Law Enforcement constitutes a deficiency in the facility's adherence to its own policies and federal requirements for reporting suspected abuse.
Failure to Address Skin Integrity in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan addressing skin integrity for a resident admitted under hospice care for a 5-day respite stay. The resident, who had a history of skin integrity issues, was noted to have a rash under her right breast upon admission. However, the Baseline Care Plan assessment did not include any information regarding her skin risk or current skin condition, as the section for skin risk was left blank. Despite the resident's known history and current skin issues, the care plan initiated the day after admission did not address skin integrity. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan assessment failed to address the resident's skin risk and the rash under her right breast. The facility's policy requires that the Baseline Care Plan be completed within 48 hours of admission and address areas of imminent concern, which was not adhered to in this case.
Failure to Address Skin Concern Leads to Worsening Condition
Penalty
Summary
The facility failed to conduct a thorough assessment and follow-up on a skin concern for a resident admitted under Hospice care for a 5-day respite stay. Upon admission, the resident had a rash under her right breast, which was noted in the Admission/Re-Admission Screener and the Shower Sheet. However, this condition was not addressed in the resident's progress notes, care plan, or treatment record. The Director of Nursing and the Licensed Practical Nurse involved were unaware of the rash under the breast, despite it being documented upon admission. The lack of communication and follow-up resulted in the rash worsening into a yeast infection, which was only discovered by a Hospice LPN four days later. The Hospice team was not informed of the skin issue, leading to a lapse in continuity of care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's skin condition, despite the family member and CNA noting the issue upon admission.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for a resident, resulting in unresolved concerns and unmet needs. The resident, who had a moderately impaired cognitive status, reported being left in a soiled incontinence brief for over six hours without proper cleaning or changing of the bed linens. The resident also mentioned a two-hour wait time after pressing the call light. The grievance was documented by the Social Service Director on behalf of the resident, and it was assigned to the Unit Manager for resolution. The investigation into the grievance was inadequate, as the Unit Manager only conducted verbal education with staff at the nurse's station without any documentation. The Social Service Director, who had recently started, was unsure of the investigation's details and relied on the Nursing Home Administrator for assistance. The facility's grievance policy required a thorough investigation to identify the root cause and take corrective action, but this was not adequately followed, leading to the deficiency.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The report identifies a deficiency in the timely reporting of an allegation of abuse involving a resident with moderate cognitive impairment. The resident alleged that a CNA and an LPN were rough while assisting her, nearly causing her to hit her head. This incident was not reported immediately to the Nursing Home Administrator (NHA) or law enforcement, as required by the facility's policies. The LPN involved delayed reporting the incident, believing the allegation to be untrue, which contributed to the failure in timely notification. Further investigation revealed that the NHA was aware of the requirement to report such allegations immediately but admitted to only reporting significant incidents to law enforcement. This practice was contrary to the facility's abuse prevention policy, which mandates immediate reporting of any suspected abuse or neglect to the appropriate authorities. The NHA's failure to report the incident to law enforcement and the state agency resulted in an incomplete investigation and left the resident unprotected from potential abuse. Additionally, another concern was raised by the resident regarding neglect, which was documented in a grievance form. The resident reported being left in soiled conditions for an extended period without proper care. This allegation of neglect was not reported to the state agency, and there was no documented investigation or corrective action taken. The facility's policy requires immediate reporting and investigation of such concerns, but these procedures were not followed, indicating systemic issues in handling allegations of abuse and neglect.
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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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