Norlite Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marquette, Michigan.
- Location
- 701 Homestead Street, Marquette, Michigan 49855
- CMS Provider Number
- 235367
- Inspections on file
- 21
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Norlite Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow its Unusual Occurrence Report policy after a resident-to-resident altercation. Two residents with Alzheimer’s disease and documented cognitive impairment were involved when one resident grabbed the other’s head while they were preparing for dinner, an event charted in the EMR as aggression toward others. An LPN reported that the residents were immediately separated and that the DON was notified due to the aggressiveness of the resident involved, but the LPN did not complete a UOR and was unaware of anyone else doing so. The NHA later acknowledged awareness of the incident but confirmed there was no completed UOR, despite facility policy requiring UOR completion and investigation for resident-to-resident altercations.
A resident with severe cognitive impairment and a documented history of aggressive behaviors, including hitting, punching, spitting, and threatening staff and other residents, grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head while both were in a common area. An LPN reported that the action was not gentle, immediately separated the residents, and notified the DON, and behavior charting noted the aggressor resident placing hands over the other resident’s hair/eyes. However, the administrator later acknowledged awareness of the incident but did not complete an Unusual Occurrence Report or a Facility Reported Incident, and there was no documentation of the event in the affected resident’s EMR, despite facility policy requiring immediate reporting, documentation, and investigation of all abuse allegations, including resident-to-resident incidents.
The facility failed to follow its abuse investigation and reporting policy after an incident in which one cognitively impaired resident with Alzheimer’s disease and a history of aggressive behaviors grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head during dinner. An LPN documented aggression toward others and reported that the resident’s action was not gentle, that the residents were separated, and that the DON was called due to the resident’s known violent behaviors. However, the administrator, though aware of the incident, did not complete an Unusual Occurrence Report or a Facility Reported Incident, and there was no documentation of the event in the affected resident’s EMR, contrary to the facility’s written abuse policy requiring immediate reporting, documentation, and thorough investigation of all alleged or suspected abuse.
The facility failed to follow its abuse reporting and investigation policy after an aggressive resident-to-resident incident. A cognitively impaired resident with Alzheimer’s disease and a history of aggressive behaviors grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head, leading staff to immediately separate them and notify the DON. Behavior charting documented aggression by the first resident, but the second resident’s record contained no note of the incident. The NHA acknowledged knowing about the event, chose not to report or investigate it, and stated that video footage was no longer available, resulting in a failure to report a reasonable suspicion of a crime and to complete required internal investigation steps.
The facility failed to maintain food safety standards, with pureed food held at improper temperatures and inadequate dishwashing practices. Additionally, the kitchen's ventilation system was insufficient, allowing steam to condense on the ceiling, potentially contaminating food. These issues were confirmed by staff and pose a risk of foodborne illness to residents.
The facility failed to provide a dignified dining experience by serving residents at the same table at different times, causing some to wait while others ate. Staff were also observed standing over residents while feeding, contrary to expected practices. The DON and CDM acknowledged these practices were not in line with facility standards, but no policies addressing these issues were found.
The facility failed to keep a medication cart locked when unattended, risking medication misappropriation for nine residents. Additionally, two expired glucose meter control solutions were not discarded, potentially affecting blood glucose readings for six residents. The DON confirmed these practices were against facility policies.
A resident experienced significant weight loss, losing 11 pounds in one month, without adequate nutritional assessment or intervention from the facility. Despite the resident's cognitive awareness and communication with the CDM about food preferences, the care plan was not updated, and the RD was not informed of the weight loss until contacted by a state surveyor. The facility's process for notifying the RD of significant weight loss was not followed, contributing to the deficiency.
A resident with a history of acute kidney failure and urine retention showed symptoms of a DVT, including pitting edema, warmth, and redness in the left leg. Despite these symptoms being documented by an LPN and communicated to the charge nurse, the physician was not notified in a timely manner, and no physician assessment was conducted. The resident was later diagnosed with a left leg DVT after being transferred to the emergency room for an unrelated issue.
Two residents in the facility were not provided with the correct therapeutic diets and fluid restrictions as prescribed. One resident, with dementia and diabetes, received incorrect meal portions and items, including pepper packets against instructions. Another resident, with congestive heart failure, exceeded fluid restrictions due to staff unawareness and inaccurate recording of fluid intake. These deficiencies highlight a lack of compliance with dietary orders and monitoring systems.
A resident experienced a 12.9% weight loss within three weeks of admission, but the facility failed to assess or prevent this loss. Despite the resident's medical conditions, there was no re-weighing or dietary progress notes. Staff interviews revealed a lack of communication and responsibility regarding dietary assessments, and the DON confirmed the absence of documentation in the EMR. The facility's Weight Management policy was not followed, leading to this deficiency.
A resident with multiple diagnoses experienced severe pain due to the facility's failure to administer pain medication on time and as prescribed. Despite a care plan and policies in place, medications like Gabapentin and Hydrocodone-acetaminophen were often given late or not at all, leading to unmanaged pain. The facility was aware of the issue but did not take sufficient action to address it.
Failure to Complete Unusual Occurrence Report After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Unusual Occurrence Report (UOR) policy after a resident-to-resident incident involving two residents with Alzheimer’s disease. An anonymous complaint to the State Agency alleged that one resident (R82) grabbed another resident’s (R90’s) head aggressively, that staff intervened, and that the Nursing Home Administrator later stated he had watched video and characterized the action as “petting” rather than an aggressive act. The complaint further alleged that this resident-to-resident incident was not reported by the facility as required. Record review showed that R82 had a diagnosis of Alzheimer’s disease and a Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 99/15, indicating severe cognitive impairment. R90 also had Alzheimer’s disease and an MDS BIMS score of 00/15, indicating cognitive impairment. Behavior charting in R82’s electronic medical record documented that on 12/06/2025 at 5:00 p.m., R82 exhibited aggression toward others, with additional information stating that the resident, while getting ready to eat dinner and standing next to R90, put his hands over her hair/eyes. This behavior entry was documented by LPN S. In an interview, the Nursing Home Administrator reported awareness of a situation between R82 and R90 about a month prior but stated he did not have a completed UOR for the event. In a separate interview, LPN S reported that on the date of the incident, R82 grabbed onto R90’s head and the two residents were immediately separated. LPN S stated that a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors, especially toward staff, but she was unsure whether the DON or any other staff member completed a UOR and confirmed that she did not complete one herself. Review of the facility’s UOR policy showed that resident-to-resident altercations are defined as unusual occurrences requiring completion and investigation of an Unusual Occurrence Report, including assessment, documentation, and follow-up, which was not done for this incident.
Failure to Protect Resident From Peer Abuse and to Report/Investigate Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own abuse reporting and investigation policies. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, and that staff intervened between the two. The complaint further alleged that two nurses reported the incident to the DON, and that the NHA later stated he had watched video and characterized the action as the aggressor resident “petting” the other resident’s head, and that the incident was not reported by the facility as a resident-to-resident event. The NHA later reported to the surveyor that he was aware of the situation between the two residents about a month prior but did not complete an Unusual Occurrence Report or a Facility Reported Incident to the State Agency. Resident #82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting and EMR notes documented a pattern of aggressive behaviors by this resident around the time of the incident, including aggression toward others, raising fists in a threatening manner at an activity aide, following a female resident and placing a hand on her back in a way that upset her, being aggressive and combative with staff during care, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple instances of hitting, punching, spitting, and pushing staff, with some incidents causing staff injury. A hospice RN documented that this resident had experienced agitation involving violence toward other residents, and facility documentation noted increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions toward care staff, as well as difficulty redirecting the resident and identifying techniques to keep staff safe. Resident #90 was also admitted with Alzheimer’s disease and had a BIMS score indicating cognitive impairment. The resident was described as elderly, blind, hard of hearing, and on hospice care. A hospice social worker note shortly before the incident described this resident as asleep in a wheelchair in the dining room, appearing comfortable and peaceful, and not arousing to verbal or gentle touch. On the date of the alleged head-grabbing incident, behavior charting for Resident #82 documented that he was standing next to Resident #90 and put his hands over her hair/eyes. LPN S, who authored this behavior note, later reported that Resident #82 grabbed onto Resident #90’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because Resident #82 was known to have extremely aggressive behaviors. LPN S stated that when Resident #82 grabbed Resident #90’s head, it was not gentle. However, review of Resident #90’s EMR progress notes over the relevant period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation of Resident #82 touching or grabbing her head on the date in question. The facility’s written policy on abuse investigation and reporting required that all alleged violations involving mistreatment, neglect, or abuse, including resident-to-resident incidents, be immediately addressed, that an Unusual Occurrence Report be completed by the charge nurse for all allegations or suspicions of abuse, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. The policy also outlined steps for investigation, including interviews, record review, and documentation of the event. In this case, despite staff reporting that Resident #82 grabbed Resident #90’s head and the facility’s knowledge of Resident #82’s ongoing aggressive behaviors toward others, the NHA acknowledged that no Unusual Occurrence Report or Facility Reported Incident was completed, and there was no documentation of the incident in Resident #90’s record. Based on the reasonable person concept, the surveyors determined that Resident #82’s action of grabbing Resident #90’s head would cause feelings of pain, fear, and intimidation, and that the facility failed to protect Resident #90’s right to be free from physical abuse by another resident and failed to follow its own abuse reporting and investigation procedures.
Failure to Investigate and Report Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its Abuse Program Policy and Procedure by not immediately identifying, documenting, and thoroughly investigating an incident of resident-to-resident abuse involving two residents. An anonymous complaint to the State Agency reported that one resident aggressively grabbed another resident’s head, that two nurses intervened, and that both nurses called the DON immediately after the incident. The complaint further alleged that the NHA later stated he had watched video footage and characterized the interaction as the resident ‘petting’ the other resident’s head, and that the incident was not reported by the facility as resident-to-resident abuse. Resident #82 was admitted with Alzheimer’s disease and had a MDS BIMS score indicating severe cognitive impairment. Behavior charting and EMR progress notes documented a pattern of aggressive behaviors by this resident around the time of the incident, including aggression toward others, raising fists in a threatening manner at an activity aide, following a female resident and placing a hand on her back in a way that upset her, aggressive behavior with staff during care, hitting staff, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple episodes of combative behavior causing staff injury. On 12/6/25 at 17:00, behavior charting documented that this resident, while getting ready to eat dinner and standing next to Resident #90, put his hands over her hair/eyes. LPN S, who wrote this note, later stated that the resident grabbed the other resident’s head, that it was not gentle, and that the two residents were immediately separated. LPN S also reported that a phone call was made to the DON to report the incident because the resident was known to have extremely aggressive behaviors. Resident #90 was also admitted with Alzheimer’s disease and had a MDS BIMS score of 0/15, indicating cognitive impairment. EMR progress notes for this resident from 10/1/25–12/12/25 contained no documentation of any aggressive physical or verbal interaction with other residents and no documentation that Resident #82 touched or grabbed her head on 12/6/25. The record also showed that Resident #90 was elderly, blind, hard of hearing, and receiving hospice care, and a hospice social worker note described her as asleep, peaceful, and not arousing to verbal or gentle touch during a visit shortly before the incident period. Despite the facility’s written Abuse; Investigative and Reporting policy requiring immediate (within two hours) reporting and investigation of all alleged or suspected abuse, completion of an Unusual Occurrence Report by the charge nurse, notification of the Administrator, and reporting allegations of abuse to the State Agency within 24 hours, the NHA acknowledged being aware of the situation between the two residents about a month prior and reported that he did not complete an Unusual Occurrence Report or a Facility Reported Incident. The investigation checklist and policy requirements for interviews, record review, and documentation were not shown to have been followed for this incident, and there was no corresponding documentation in Resident #90’s record, demonstrating the facility’s failure to fully implement its abuse investigation and reporting procedures.
Failure to Report and Investigate Resident-to-Resident Aggression as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation and reporting policy and to report a reasonable suspicion of a crime under Section 1150B of the Act after an aggressive resident-to-resident incident. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, that two nurses intervened and reported the incident to the DON, and that the NHA later stated he had watched video and believed the resident was only petting the other resident’s head. The complaint further alleged this resident-to-resident incident was not reported by the facility. The facility’s written policy required that all allegations or suspicions of abuse, including mistreatment and injuries of unknown source, be immediately addressed, that an Unusual Occurrence report be completed by the charge nurse, that the Administrator be notified, that an investigation be initiated within 24 hours, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. Resident 82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting for this resident documented aggression toward others, including an entry on 12/06/2025 at 17:00 stating that the resident, while getting ready to eat dinner and standing next to another resident, put his hands over her hair/eyes. LPN S, who documented this note, later reported that she was working at the time of the incident when the resident grabbed onto the other resident’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because this resident was known to have extremely aggressive behaviors such as hitting, punching, spitting, swinging, kicking, and reaching out toward others. LPN S stated that when the resident grabbed the other resident’s head, it was not gentle. Additional behavior charting for this resident on subsequent dates documented further aggressive behaviors, including raising fists in a threatening manner and following a female resident, placing a hand on her back and reaching toward her again, which upset the other resident. Resident 90, the other resident involved, was also admitted with Alzheimer’s disease and had a BIMS score of 0/15, indicating cognitive impairment. Her EMR progress notes over a several‑month period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation that the aggressive resident touched or grabbed her head on the date of the incident. Her record also indicated that she was elderly, blind, hard of hearing, and receiving hospice care. The NHA acknowledged in an interview that he was aware of a situation between these two residents about a month prior, that he did not report or investigate the occurrence because he felt it did not rise to the level of being reportable or needing investigation, and that he no longer had video footage of the occurrence. This combination of staff reports, behavior charting, and the NHA’s decision not to report or investigate, despite the facility’s abuse policy requirements, formed the basis of the cited deficiency.
Deficiencies in Food Safety and Kitchen Ventilation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a morning meal service. A stainless steel pan containing pureed eggs, sausage, and hashbrown potatoes was found on the steam table at a temperature of 115°F, which is below the required 135°F for hot holding. The food service worker, identified as [NAME] B, was unaware of the correct reheating temperature of 165°F and had not measured the temperature after the pureeing process. This oversight has the potential to result in foodborne illness among the facility's 76 residents. Additionally, the facility's dishwashing practices were found to be inadequate. A food service worker, identified as FSW C, was observed washing and rinsing food preparation equipment and then immersing them in a sanitizing solution for only two seconds, contrary to the required 60 seconds for proper sanitization. The worker was unaware of the correct immersion time, which is necessary to ensure the equipment is properly sanitized and safe for use. The facility also exhibited deficiencies in its kitchen ventilation system. The exhaust hood was unable to capture the steam released from the steamer equipment, resulting in condensation on the kitchen ceiling and potential contamination of food. The exhaust system was found to have a weak pull and was not properly engineered to handle the volume of steam and smoke produced, nor did it provide adequate make-up air to balance the exhaust volume. This ongoing issue was confirmed by the kitchen manager, indicating a long-standing problem with the facility's ventilation system.
Deficient Dining Experience and Feeding Practices
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the dining room, as observed during meal services. During lunch, several tables with multiple residents were partially served, resulting in some residents eating while others at the same table waited for their meals. This led to situations where residents were left waiting for extended periods, with one resident waiting from before 12:30 PM until 1:05 PM to be served. Similar issues were observed during breakfast, where residents at the same table were served at different times, causing some to wait while others ate. Staff members were observed serving meals in no particular order, contributing to the delays. Additionally, staff members were observed standing over residents while assisting with feeding, which was acknowledged by both a Registered Nurse and a staff member as not being the appropriate practice. The Director of Nursing confirmed that the expectation was for staff to be seated while feeding residents. The Certified Dietary Manager stated that the standard practice should be to serve the same table at the same time, but this was not reflected in the facility's training program or policies. No further policies addressing these issues were provided before the survey concluded.
Medication Cart Security and Expired Glucose Solutions
Penalty
Summary
The facility failed to ensure that a medication cart on the 500 unit remained locked when unattended, as observed on two separate occasions. This oversight was confirmed during an interview with the Director of Nursing (DON), who stated that the expectation is for medication carts to be locked when not in use. The unlocked cart posed a potential risk for the misappropriation of medications for the nine residents on the unit. Additionally, the facility did not discard two expired glucose meter control solutions, which were found on the countertop in the medication storage room. The control solutions had been opened beyond the recommended three-month period, as indicated by the dates written on the bottles. The Licensed Practical Nurse (LPN) present during the inspection was unaware of other available control solutions, although unopened boxes were found in a cupboard. The DON confirmed that the expired solutions should have been discarded within 90 days of opening, as per the facility's policy and the manufacturer's instructions. This failure could lead to inaccurate blood glucose readings for six residents receiving blood glucose testing.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional assessment and interventions for a resident who experienced significant weight loss. The resident, who was cognitively intact, reported losing weight and expressed dissatisfaction with the food, noting that scrambled eggs were often served cold. Despite discussing food preferences with the Certified Dietary Manager (CDM), the resident did not see any changes. The resident's electronic medical record indicated an 11-pound weight loss over one month, which was not promptly addressed by the facility. The care plan was not updated to reflect necessary nutritional interventions following a diet order change. The Registered Dietician (RD) was not informed of the resident's significant weight loss until contacted by a state surveyor. The RD stated that the facility's process for referral was not followed, as she was not notified via the referral list or phone call. The Director of Nursing (DON) confirmed that the RD should have been notified of any significant weight loss, defined as a 5% or greater loss in a month. Despite the facility's policy requiring notification of dietary concerns, the RD was unaware of the resident's condition until after the surveyor's involvement. The facility's failure to reweigh the resident or notify the RD in a timely manner contributed to the deficiency.
Failure to Monitor Change in Condition
Penalty
Summary
The facility failed to ensure that a change in condition for a resident was assessed and monitored by the attending physician. The resident, who had a history of acute kidney failure and urine retention, exhibited symptoms indicative of a deep vein thrombosis (DVT), including moderate pitting edema, warmth, and redness in the left lower leg. Despite these symptoms being documented by an LPN and communicated to the charge nurse, the physician was not notified in a timely manner, and no physician assessment was conducted following the initial identification of these symptoms. The resident was later transferred to the emergency room for an unrelated concern, where a diagnosis of left leg DVT was confirmed. The facility's policy required documentation of observations and physician notification, but no Change in Condition form was found for the resident. Interviews with the DON and a clinical consultant confirmed that the resident was not evaluated by a physician after the symptoms were identified, and the diagnosis of DVT was considered untimely.
Failure to Adhere to Therapeutic Diets and Fluid Restrictions
Penalty
Summary
The facility failed to ensure that a correct therapeutic diet was prescribed and served to two residents, leading to potential unmet nutritional needs and health complications. Resident #25, who was admitted with diagnoses including dementia, dysphagia, and diabetes mellitus, was observed receiving incorrect meal portions and items not aligned with the prescribed diet. The resident was supposed to receive a carbohydrate-controlled diet with no added salt and pureed food, but was served mixed items and incorrect portion sizes. Additionally, the resident received pepper packets despite instructions to exclude them, potentially due to a risk of consuming the packets themselves. Resident #41, diagnosed with chronic congestive heart failure, high blood pressure, and diabetes mellitus, was on a physician-ordered fluid restriction. However, the resident was observed consuming fluids exceeding the prescribed limits during meals and other times, such as activities. The staff, including an LPN, appeared unaware of the fluid restriction, leading to the resident consuming more fluids than allowed. The fluid intake was inaccurately recorded, and the resident was served additional fluids despite the restriction. The facility's failure to adhere to prescribed dietary and fluid restrictions for these residents indicates a lack of compliance with dietary orders and monitoring systems. The dietary manager and staff interviews revealed a lack of understanding and adherence to the therapeutic menus and fluid restriction plans, contributing to the deficiencies observed during the survey.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to assess and prevent a significant weight loss for a resident, identified as R2, who experienced a 12.9% weight loss within three weeks of admission. R2 was admitted with multiple diagnoses, including a fracture, cellulitis, and a Stage II pressure ulcer. Despite these conditions, there was no evidence of re-weighing to verify the significant weight loss, nor were there any dietary progress notes completed by the Certified Dietary Manager (CDM) or the Consultant Registered Dietitian (RD). Interviews revealed a lack of communication and responsibility among staff regarding dietary assessments. The Assistant Dietary Manager was unaware of the dietitian's visits, and the CDM did not document the weight loss due to a policy requiring a referral to the dietitian. The CDM mentioned that nursing was responsible for adding new admissions to a dietary referral sheet, but R2's significant weight loss was not addressed. The Consultant RD was also unaware of R2's condition, indicating a breakdown in the referral process. The Director of Nursing (DON) confirmed the absence of progress notes in the Electronic Medical Record (EMR) for R2's weight loss. A list of dietitian referrals showed R2 as a new admission, but the RD had not completed an assessment. The facility's Weight Management policy required re-weighing and dietary notification for weight discrepancies, but these procedures were not followed, leading to the deficiency in care for R2.
Failure in Timely Pain Management for a Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R2, who was admitted with multiple diagnoses including a fracture, cellulitis, and a pressure ulcer. Despite having a pain management plan in place, the facility consistently administered pain medication late and failed to administer PRN medications as needed. R2's pain was documented as severe, often reaching a 10 on the pain scale, yet the facility did not adhere to the prescribed medication schedule. R2's medical records indicated that pain medications such as Gabapentin and Hydrocodone-acetaminophen were either not administered or given late on multiple occasions. The resident's pain care plan, which aimed to maintain pain levels at a manageable level, was not effectively implemented. The facility's policy required pain assessments and timely medication administration, but these were not consistently followed, leading to prolonged periods of unmanaged pain for R2. Interviews with the complainant and the Director of Nursing revealed awareness of the issues, with complaints about the late administration of pain medication being raised multiple times. Despite these concerns, the facility did not take adequate steps to ensure timely pain relief for R2, resulting in the resident experiencing significant discomfort and distress during their stay.
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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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