Northville Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Northville, Michigan.
- Location
- 520 W Main St, Northville, Michigan 48167
- CMS Provider Number
- 235730
- Inspections on file
- 21
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northville Manor during CMS and state inspections, most recent first.
The facility did not ensure that posted menus matched the meals actually served, nor did it update or document menu changes when substitutions occurred. Staff and dietary management failed to promptly communicate or post revised menus, and substitution logs were not maintained in a timely manner, affecting nearly all residents who consumed meals from the kitchen.
Surveyors found that the facility failed to maintain a clean and safe environment, with soiled light fixtures, missing safety devices on plumbing, corroded faucets, damaged furniture, and stained carpeting. These deficiencies affected 28 residents and were not addressed through the facility's manual work order and cleaning schedules, as required by policy.
Several residents were not provided a dignified dining experience, as staff were observed standing over residents while assisting with feeding, and meals were served using assorted and inadequate dinnerware such as plastic utensils and small plates. One resident expressed a preference for real silverware over plastic, and some residents experienced delays in starting their meals due to missing utensils or napkins. The facility's policy did not specifically address dignity practices during dining.
The facility did not provide necessary behavioral health care to several residents with severe cognitive and psychiatric diagnoses, as evidenced by extended lapses in psychiatric follow-up and ongoing behavioral symptoms. Staff interviews and record reviews confirmed that psychiatric services were not delivered as required, leaving residents without needed assessments or interventions.
Surveyors found that a medication cart contained 13 loose pills of various types, which had not been properly cleaned or discarded as required by facility policy. Additionally, expired medications, including Geri Lanta and Benadryl, were discovered in the medication storage room, despite staff being responsible for regular checks and removal. These deficiencies were confirmed through staff interviews and review of facility procedures.
CNAs served meals without hair restraints and handled eating surfaces of utensils without gloves, while also passing drinks by holding cups at the rim, leading to potential food contamination for nearly all residents consuming food from the kitchen. The Dietary Manager confirmed these practices were not in line with facility expectations or food code requirements.
Medications ordered to be given at specific times were administered late to several cognitively impaired residents after a nurse was delayed by a medical emergency. The nurse did not notify the DON about the delay, and the DON did not consult the provider regarding the late doses, despite facility policy requiring timely administration and physician involvement in schedule changes.
A resident with adjustment disorder and asthma was not provided with documentation or education regarding influenza and pneumococcal vaccinations. The DON confirmed that the resident's record did not show the vaccine was offered, administered, refused, or contraindicated, despite facility policy requiring annual immunization offers and documentation.
Surveyors identified that several rooms did not meet the required minimum square footage per resident, with multiple rooms housing more residents than the available space allows. Despite interviews revealing no specific complaints or health/safety concerns from residents, the deficiency was confirmed through direct measurement and review of facility records.
A resident with Alzheimer's and severe cognitive impairment was improperly restrained with a sheet by a CNA to prevent her from leaving her chair. The facility lacked documentation for restraint use, violating its restraint-free policy.
A resident with Alzheimer's and other conditions experienced a fall, but the facility failed to update the care plan to reflect this incident. Despite the facility's policy requiring care plan revisions upon status changes, the care plan had not been updated since 2022, and the Director of Nursing acknowledged the oversight.
The facility did not maintain the required RN coverage of eight consecutive hours daily, affecting all 27 residents. Staffing timecards showed gaps in coverage on specific dates, and the DON acknowledged the issue, citing an RN's extended vacation as a contributing factor. The facility's policy mandates RN services for at least 8 consecutive hours per day, 7 days a week.
The facility failed to maintain food service equipment and properly date mark ready-to-eat food, affecting 27 residents. Observations revealed soiled equipment, missing light assembly end caps, and improperly dated milk. These issues violated the 2017 FDA Model Food Code, which requires clean equipment and proper date marking for safety.
The facility experienced deficiencies in internal programs due to leadership changes, affecting all residents. Delays in MDS assessments, inadequate RN coverage, and lack of CNA training were noted. The Infection Control Program was insufficient, with outdated policies and missing documentation. An abuse incident was reported late due to administrative changes. The facility owner acknowledged the issues but was unaware of specific concerns.
The facility failed to implement a comprehensive infection control program, leading to missed corrective actions and potential infection spread. The DON, newly certified as an Infection Preventionist, had not documented infection tracking or antibiotic stewardship since November 2023. The facility's Influenza Vaccination policy was outdated, and the staff call-in log was unavailable. The NHA acknowledged the need for an appointed Infection Preventionist and completion of necessary work.
The facility failed to maintain a clean and safe environment, with observations of accumulated dust, dirt, and debris in common areas and resident rooms. Safety hazards included a loose and rotted handrail and uncovered electrical junction boxes. A resident's room remained soiled over several days, despite being on the cleaning schedule, indicating inadequate housekeeping practices.
The facility failed to submit MDS assessments to CMS on time for six residents due to a backlog caused by the absence of an MDS coordinator for three months. The newly hired LPN acknowledged the delay, with submission deadlines missed for several residents. The facility's policy requires assessments to be transmitted within 14 days of completion, but this was not adhered to, potentially delaying the monitoring of residents' care quality.
The facility did not ensure CNAs completed the required 12 hours of annual in-service education, affecting four CNAs hired between 2021 and 2023. The DON admitted to having no records of such training and acknowledged that no formal in-service trainings had been conducted. The facility's assessment tool confirmed the annual training requirement.
The facility failed to store medications at recommended temperatures and did not consistently document refrigerator temperatures, affecting 12 residents. Medications requiring specific temperature ranges were improperly stored, impacting residents with conditions like glaucoma and diabetes. The DON acknowledged missing documentation and emphasized the responsibility of nurses to maintain temperature logs and report deviations.
The facility failed to obtain consents for immunizations for three residents and did not offer influenza and pneumococcal vaccines to another resident, leading to a deficiency in ensuring informed decision-making and potential spread of infections. Three residents received vaccines without documented consent, and one resident was not documented as having received, been offered, or refused the vaccines.
A facility failed to supervise residents, resulting in a physical altercation between two residents, causing injuries. The incident occurred in an unsupervised dining room during a shift change. One resident, with a history of wandering, was attacked by another resident with known behavioral issues. The facility's policy required staff awareness of residents' needs, but the lack of supervision and failure to separate residents with behavioral issues led to the incident.
The facility failed to report an abuse incident involving two residents to the State Agency within the required timeframe. An LPN intervened in an altercation where one resident was injured, and although immediate actions were taken, the incident was not reported to the state agency until ten days later, contrary to the facility's policy requiring a report within two hours.
A facility failed to monitor the weight of a high-risk resident with cerebral palsy and moderate protein-calorie malnutrition. Despite being on tube feeding, the resident did not have an admission weight recorded, nor were weekly weights documented during the initial weeks of residency, contrary to the facility's policy. This oversight was confirmed by both the RD and DON, highlighting a lapse in monitoring the resident's nutritional status.
A resident expressed dissatisfaction with meals as her food preferences were not honored. She requested vegetables like carrots and green beans, but no alternatives were offered. The Dietary Manager stated that an alternate menu was available, but it was not provided to the resident. The Nursing Home Administrator acknowledged the need for residents to be aware of the always available menu and the lack of follow-through on the resident's requests.
The facility did not have an Infection Preventionist (IP) as a member of the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) committee for three quarters. The sign-in sheets for meetings in September 2023, January 2024, and May 2024 lacked an IP signature. The previous NHA, who also served as DON, was supposed to fulfill the IP role, but their credentials could not be verified. The current DON received IP certification only after the last QAA meeting, contrary to the facility's policy requiring an IP in the committee.
The facility did not provide the required 80 square feet of space per bed in six resident rooms, with room sizes ranging from 144 to 283 square feet for multiple beds. Despite this, no specific complaints or health/safety concerns were reported by residents.
Failure to Post and Update Menus Following Meal Substitutions
Penalty
Summary
The facility failed to ensure that posted menus accurately reflected the meals served to residents and that menu changes were properly documented and communicated. On one occasion, the posted lunch menu listed braised beef tips, parsley noodles, seasoned carrots, wheat rolls, and Boston cream pie, but residents were instead served hamburgers with buns, lettuce, tomato, onion, pickles, and ice cream. The Dietary Manager explained that a new employee had used the meat intended for a different meal, leading to a last-minute substitution. Although residents were consulted about the substitute menu, there was no evidence that the menu changes were formally posted or that meetings regarding these changes were documented. Further review of the substitution log revealed additional instances where planned menu items were replaced with alternatives, such as potato salad being substituted with potato chips and salmon croquettes being replaced with pizza and salad. These substitutions were not promptly documented, and staff were unaware that posted menus should be updated to reflect changes. Additionally, for special occasions like Easter, planned menu changes were not communicated to residents or posted in advance. No additional evidence was provided by facility leadership to explain the lack of updated or posted menus in accordance with the changes made.
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including soiled and dirty surfaces, missing safety devices, and worn or damaged furnishings. Specifically, a resident restroom had an overhead light lens cover contaminated with dust, dirt, and dead insects. Another restroom had a corroded and particulate-laden faucet assembly, and a shower room was missing an atmospheric vacuum breaker on the shower wand assembly. The nursing station contained a black vinyl padded chair with exposed inner padding due to wear, and the hallway corridor and day room carpeting were stained, worn, and buckled, with a large red stain noted beneath the resident call system panel. Additionally, several resident rooms had overbed light shades and a stationary desk fan that were heavily soiled with accumulated dust and dirt deposits. Interviews with the Director of Maintenance revealed the facility uses a manual work order system, with the maintenance logbook kept at the nurses station. Review of facility policies indicated requirements for a preventative maintenance program and cycle cleaning schedules to ensure a safe, sanitary, and comfortable environment. However, the observed conditions demonstrated a failure to effectively implement these policies, resulting in unclean and poorly maintained areas that affected 28 residents and increased the likelihood of cross-contamination and bacterial harborage.
Failure to Ensure Dignified Dining Experience and Consistent Use of Appropriate Dinnerware
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as evidenced by staff standing over residents while assisting with feeding and serving meals with an assortment of inadequate dinnerware. One resident, who was alert and oriented, expressed dissatisfaction with being served food on plastic plates and using paper and plastic utensils, preferring real silverware. Observations showed plastic ware on the resident's bedside table. During lunch, a nurse was seen standing over a resident while feeding, intermittently leaving to check the medication cart, and placing food in the resident's mouth and hands without consistent engagement. Another resident was observed self-propelling out of the dining room wearing a soiled clothing protector, which was only addressed after the resident returned. Some residents were left without napkins or plastic ware, causing delays in starting their meals and requiring staff assistance to cut food. Further observations revealed that approximately 15 residents were served meals with a mix of Styrofoam cups, dessert plates, plastic utensils, and small melamine plates that were insufficient for the meal portions. The dietary manager confirmed that a full set of dishes was available and the dish machine was operational, but could not explain why assorted dinnerware was used. Staff interviews indicated that the dining room sometimes became crowded, making it difficult to provide one-on-one feeding assistance at an appropriate level. A review of the facility's policy on promoting and maintaining resident dignity showed it did not specifically address dignity practices during dining.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to five out of twelve residents reviewed for behavioral health needs. Multiple residents with diagnoses such as Alzheimer's disease, major depressive disorder, dementia, anxiety, and psychotic disorders had not received timely psychiatric services. For example, one resident with severe cognitive impairment and a history of behavioral symptoms had not been seen by a psychiatric practitioner since August of the previous year, despite being prescribed psychotropic medications and having care plans that called for psychiatric consults as needed. Observations included residents exhibiting behaviors such as yelling out, crying, banging objects, and expressing confusion about their identity, with documentation showing significant lapses in psychiatric follow-up. Several residents had not received psychiatric services for extended periods, ranging from several months to over half a year, despite ongoing behavioral symptoms and care plans indicating the need for such services. Staff interviews confirmed that psychiatric services were not being provided as expected, with the DON and social worker acknowledging the absence of a current psychiatric provider and gaps in service delivery. The lack of psychiatric services was further corroborated by record reviews and staff interviews, which revealed that the facility did not have an active psychiatric group servicing the building for a period of time. This resulted in residents with significant behavioral health needs not receiving the necessary assessments or interventions, as outlined in their care plans and physician orders. The deficiency was identified through direct observation, interviews with staff, and review of medical records.
Failure to Maintain Medication Cart Cleanliness and Timely Disposal of Expired Medications
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications in one medication cart, as observed during an inspection of the North Hall medication cart. Thirteen loose pills of various shapes, colors, and sizes were found scattered in the drawers of the cart. Interviews with nursing staff and review of facility policy revealed that nurses are expected to clean the cart and discard any loose medications, with the midnight shift specifically assigned this responsibility. However, the presence of loose pills indicated that this procedure was not followed as required by facility policy. Additionally, the facility did not dispose of expired medications in a timely manner. During an inspection of the medication storage rooms, expired medications, including Geri Lanta and Benadryl, were found. The DON confirmed that medication supply staff are responsible for checking and removing expired medications, with weekly and monthly checks expected. Facility policy states that expired medications should be reported to the nurse manager, but the expired items remained in storage, indicating a lapse in adherence to established protocols.
Failure to Ensure Hygienic Practices During Meal Service
Penalty
Summary
Certified Nurse Aides (CNAs) were observed serving meals to residents without using any form of hair restraint or having their hair pulled back, which resulted in the potential for food contamination. Specifically, two CNAs had long, loose braided hair extensions that hung over their shoulders and down their backs, while another CNA with long natural hair was seen repositioning her hair behind her ears to prevent it from touching residents' food. Additionally, this CNA was observed wrapping silverware without wearing gloves and handling the eating surfaces of the utensils while wrapping them in napkins. Another CNA poured beverages and passed drinks to residents by holding the cups at the rim, rather than the base, increasing the risk of contamination. The Dietary Manager confirmed that staff should not have been handling the eating portions of the utensils and that gloves should have been worn during this process. The facility's provided policy, titled "Dress Code," was not specific to food service personnel and only stated that employees with long hair may be required to wear a hair net depending on their duty assignment or work area. The 2009 Michigan Modified Food Code requires food employees to wear hair restraints to prevent hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service articles. These observations affected 27 of the 28 residents who consumed food from the kitchen.
Failure to Administer Medications According to Physician Orders and Scheduled Times
Penalty
Summary
The facility failed to ensure that medications were administered according to physicians' orders and within the scheduled time frames for three residents. Observations showed that a registered nurse administered 9 AM medications to multiple residents several hours after the scheduled time. The medications included Keppra, Metoprolol, Duloxetine, and others, all of which were ordered to be given twice daily at specific times. The nurse reported being delayed due to a medical emergency earlier in the day but did not notify the Director of Nursing (DON) about the delay or seek guidance regarding the late administration of medications. Record reviews indicated that the affected residents had significant cognitive impairments and multiple diagnoses, including seizure disorders, dementia, depression, and heart disease. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time, and any adjustments to the schedule were to be made by a physician. The DON confirmed awareness of the late administration but did not contact the provider to determine if the late doses should be rescheduled. The Nursing Home Administrator stated that the expectation was for medications to be administered as ordered.
Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that a resident was provided with pneumococcal vaccination and education, as well as documentation regarding the influenza vaccine. During interviews, the DON/Infection Preventionist confirmed that there was no documentation in the resident's electronic health record indicating that the influenza vaccine was offered, administered, refused, or contraindicated. The resident in question had diagnoses including adjustment disorder with mixed anxiety and depressed mood, and asthma, and had been admitted to the facility without proper immunization documentation. Further review of facility policy revealed that it requires annual offering and documentation of influenza vaccination or refusal, as well as education about the benefits and side effects of immunization. Despite this policy, the resident's record lacked evidence that the vaccine was offered or that education was provided, and the DON acknowledged that the resident should have been given the opportunity to receive the influenza vaccine for the current flu season.
Resident Rooms Below Required Square Footage Standards
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in six out of fifteen resident rooms, as determined through observation, interviews, and record review. Specifically, rooms were found to have less than 80 square feet per resident in multiple occupancy rooms and less than 100 square feet in single occupancy rooms. The review of facility bed count information with the Nursing Home Administrator confirmed that several rooms, including those with two to four beds, did not meet the required space standards. Although residents interviewed did not express specific complaints or health and safety concerns, the deficiency was identified based on the physical measurements and occupancy of the rooms.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to prevent the use of physical restraints on a resident, identified as R401, who was observed sitting in a chair with a sheet wrapped around her waist and tucked behind the chair, effectively restraining her. This incident was reported by a CNA who found the resident in this condition. The resident, who has a history of Alzheimer's disease and severe cognitive impairment, was unable to answer questions due to confusion. The CNA involved admitted to wrapping the sheet around the resident to prevent her from getting up, as the resident was entering other residents' rooms and not following instructions. The facility's records revealed no orders, consents, assessments, or care plans for the use of restraints on R401. The facility's policy, which was implemented in November 2022, states that the environment should be restraint-free unless there are medical symptoms that warrant restraint use. The Nursing Home Administrator and Director of Nursing confirmed that the facility is supposed to be restraint-free and acknowledged the lack of documentation supporting the use of restraints for R401.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the care plan for a resident in a timely manner following a fall incident. The resident, who has Alzheimer's disease, adjustment disorder with mixed anxiety, depressed mood, and major depressive disorder, was admitted to the facility with severely impaired cognition. An incident report was submitted to the State Agency after the resident sustained an injury of unknown origin, and it was noted that the resident had a slight discoloration under the left eye. Despite a fall occurring on 12/10/2024, the resident's care plan, which was last reviewed on 12/8/2024, had not been updated since 9/6/2022 to reflect this incident or any new interventions. The Director of Nursing acknowledged that the care plan should have been updated to include the recent fall and any necessary changes to the resident's care. The facility's policy requires that care plans be reviewed and revised when a resident experiences a status change, involving notification of the MDS Coordinator, physician, and resident representative, if applicable. The policy also outlines the procedure for updating care plans, including team discussions, documentation, and communication of interventions to staff. However, these steps were not followed in this case, leading to the deficiency.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which is a requirement for adequate coordination of care. This deficiency affected all 27 residents in the facility. The issue was identified through a review of staffing timecards, which revealed that there was no consecutive 8-hour RN coverage on specific dates in April and May 2024. During an interview, the Director of Nursing (DON) acknowledged the staffing problem and mentioned that another RN, who usually worked midnights and weekends, was on an extended vacation. The DON confirmed that they had recently hired another RN to help cover the shifts when the DON was not working. The facility's policy requires the utilization of RN services for at least 8 consecutive hours per day, 7 days a week.
Deficiencies in Food Service Equipment Maintenance and Date Marking
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and properly date mark potentially hazardous ready-to-eat food products, affecting 27 residents. During an initial tour of the food service area, a half-gallon of Prairie Farms whole milk was found in the Traulsen 2-door reach-in cooler without an open or out date, despite having a manufacturer's use-by-date of May 26. The Dietary Manager stated that products are date marked when opened for a total of 7 days, if the manufacturer's use-by-date allows. This practice did not comply with the 2017 FDA Model Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked for consumption, sale, or disposal within 7 days when held at 5°C (41°F) or less. Additionally, several pieces of food service equipment were observed to be heavily soiled. The Traulsen 2-door reach-in cooler and freezer door gaskets, the can opener assembly mounting plate, the Ice-O-Matic ice machine interior plastic resin retention plate, and the garbage disposal overhead spray valve assembly were all noted to have accumulated and encrusted dirt, dust, and food debris deposits. These conditions violated the 2017 FDA Model Food Code, which mandates that equipment food-contact surfaces and utensils be clean to sight and touch, and that non-food-contact surfaces be free of dust, dirt, food residue, and other debris. Furthermore, 11 of 24 overhead light assembly end caps were missing, which is a violation of the 2017 FDA Model Food Code that requires light bulbs to be shielded, coated, or otherwise shatter-resistant in areas with exposed food, clean equipment, utensils, and linens. The basement's Kelvinator refrigerator interior flooring surface was also severely corroded and particulate, with a new refrigerator on order. The facility's policies and procedures for sanitation inspections and ice machine maintenance were reviewed, revealing that the facility aims to keep food service areas clean and sanitary, and to ensure ice machines are properly maintained to prevent microbial contamination.
Leadership Changes Lead to Deficiencies in Internal Programs
Penalty
Summary
The facility failed to maintain continuity of internal programs during leadership changes, affecting all 27 residents. The Minimum Data Set (MDS) assessments were delayed due to the absence of an MDS Coordinator for about three months, resulting in assessments being over 120 days late for several residents. The Nursing Home Administrator (NHA) acknowledged the lapse and the need for timely completion and submission of MDS assessments in accordance with state regulations. Staffing issues were also identified, with the Director of Nursing (DON) acknowledging the lack of consecutive 8-hour Registered Nurse (RN) coverage. The facility had recently hired another RN to address this issue, but the DON admitted there was a problem with staffing. Additionally, the facility failed to provide the required 12-hour Certified Nurse Assistant (CNA) in-service and competencies training, including abuse and dementia training, as there were no records from the previous DON, and no formal in-service training had been conducted by the current DON. The facility's Infection Control Program was found to be lacking, with documentation of infection identification, tracking, monitoring, and antibiotic stewardship ending in November 2023. The DON, who became certified as an Infection Preventionist in May 2024, was unaware of the location of the staff call-in log. The facility's Influenza Vaccination policy had not been updated since November 2022. Furthermore, there was an eleven-day delay in reporting a resident-to-resident abuse incident to the State Agency, which the NHA attributed to administrative changes during that period. The facility owner/CEO acknowledged the leadership changes and the need for improvement but was unaware of specific concerns due to a lack of communication.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to consistently implement a comprehensive infection control program, which resulted in missed opportunities for corrective actions and the potential spread of infectious organisms throughout the facility. The Director of Nursing (DON), who was also the Infection Preventionist, had only recently received certification on 5/20/24, and the previous Infection Preventionist's employment ended in November 2023. Since then, there had been no documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, responding follow-up activity, or antibiotic stewardship. Additionally, the facility's Influenza Vaccination policy had not been updated since 11/1/22, and the staff call-in log, which documents the staff's reasons for calling in, was unavailable for review. The DON was unable to locate or access this log. The Nursing Home Administrator acknowledged that an Infection Preventionist should have been appointed and the necessary work completed. The facility's policy on the Infection Prevention and Control Program, dated 3/13/24, outlined the need for a system of surveillance and an antibiotic stewardship program, but these were not being effectively implemented.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and the public, as evidenced by several observations during an environmental tour. The common areas, including a resident restroom, dining room, and day room, were found to have accumulated dust, dirt, and debris, indicating inadequate cleaning practices. Additionally, the front entrance handrail was loose and rotted, posing a safety hazard. The laboratory specimen refrigerator was also improperly maintained, with soiled surfaces and an incorrect temperature reading, which could compromise the integrity of stored specimens. Further deficiencies were noted in the resident rooms, where issues such as damaged drywall, uncovered electrical junction boxes, loose fixtures, and non-functional lighting were observed. One room was described as extremely malodorous, suggesting a lack of proper sanitation and ventilation. These conditions were not documented in the maintenance log, indicating a failure in the facility's maintenance tracking and response system. The facility's policies on cycle cleaning and environmental inspections were not effectively implemented, as evidenced by the persistent cleanliness issues. A specific resident's room remained soiled over several days, despite being on the cleaning schedule, highlighting a gap in housekeeping execution. The housekeeper responsible for cleaning expressed difficulty in managing her workload, which may have contributed to the ongoing cleanliness issues in the facility.
Delayed MDS Submissions
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were signed and submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for six residents. This deficiency was identified during an interview and record review, revealing that the facility was significantly behind in MDS submissions due to the absence of a dedicated MDS coordinator for approximately three months. The newly hired Licensed Practical Nurse (LPN) and MDS Coordinator, who started on March 25, 2024, acknowledged the backlog and confirmed that several assessments were overdue for submission. The specific residents affected by this delay included Resident #2, Resident #12, Resident #15, Resident #20, Resident #21, and Resident #22, with submission deadlines ranging from March 30, 2024, to May 6, 2024. The facility's policy, dated February 23, 2024, mandates that all assessments be transmitted to the designated CMS system within 14 days of completion. The Nursing Home Administrator expressed expectations for timely submissions to comply with state regulations and facility policies. However, the lack of a timely submission process resulted in a delay in monitoring the quality of care provided to the residents and potentially delayed the identification of health concerns.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) completed the required 12 hours of in-service education annually, affecting four out of five CNAs reviewed. The CNAs in question were hired between June 2021 and September 2023, and there was no evidence of the required training being provided by the facility. During an interview, the Director of Nursing (DON) acknowledged the absence of records for the 12-hour in-service training and admitted that no formal in-service trainings had been conducted since taking over the role. The facility's assessment tool, updated in May 2024, confirmed the requirement for CNAs to receive at least 12 hours of in-service training annually to ensure their continuing competence.
Improper Medication Storage and Documentation
Penalty
Summary
The facility failed to store biologicals and medications at the recommended temperature parameters for 12 residents and did not consistently document refrigerator temperatures for 27 residents. Observations revealed that the medication refrigerator temperature was at 32 degrees Fahrenheit, which is below the recommended range of 36 to 46 degrees Fahrenheit for certain medications. The temperature monitoring logs from January to May 2024 showed multiple omissions and instances where temperatures were recorded below the recommended range. The medications affected included Latanoprost Ophthalmic Solution, Influenza Vaccine, Tuberculin Purified Protein Derivative, Pneumococcal Vaccine, and various insulin products, which require storage between 36 and 46 degrees Fahrenheit. Additionally, medications like Refresh Tears and Brimonidine Tartrate Ophthalmic Solution, which should be stored between 58 and 86 degrees Fahrenheit, were also improperly stored. The residents affected had various medical diagnoses, including glaucoma, type 2 diabetes mellitus, and age-related nuclear cataract, and were prescribed these medications as part of their treatment. The Director of Nursing acknowledged the missing documentation and stated that it was the nurses' responsibility to fill out the temperature log daily and report any deviations to maintenance. The facility's policy on medication storage requires staff to report improper storage temperatures and not administer medications exposed to such conditions. However, the failure to adhere to these procedures led to the deficiency in medication storage and documentation.
Failure to Obtain Vaccine Consents and Offer Immunizations
Penalty
Summary
The facility failed to obtain consents for immunizations for three residents and did not offer influenza and pneumococcal vaccines to one resident, leading to a deficiency in ensuring informed decision-making and potential spread of infections. Specifically, three residents, who were all over the age of 65, received vaccines without documented consent. Resident #6 and Resident #8 received the influenza vaccine, while Resident #10 received both the influenza and pneumococcal vaccines, all without proper consent documentation. Additionally, Resident #18, who had been in the facility during the previous flu season, was not documented as having received, been offered, or refused the influenza and pneumococcal vaccines. The facility's policies required signed consent forms for vaccinations, which were not adhered to in these cases. The Nursing Home Administrator acknowledged the need for completed consent forms to ensure evidence of consent and education, but no additional documentation was provided to address these deficiencies.
Failure to Supervise Residents Leads to Physical Altercation
Penalty
Summary
The facility failed to supervise residents adequately, leading to a physical altercation between two residents, resulting in one resident sustaining physical injuries. The incident occurred in the dining room during a shift change when a Licensed Practical Nurse (LPN) heard a commotion and found one resident grabbing and scratching another. The LPN intervened to stop the altercation. Interviews revealed that the dining room was unsupervised at the time, and the facility was aware of the behavioral issues of the involved residents. One resident had a history of wandering and getting into others' personal space, while the other had past behavioral issues, including verbal yelling and physical aggression. The involved residents had significant medical histories, with one diagnosed with Alzheimer's Disease and Major Depressive Disorder, and the other with Schizoaffective Disorder, Altered Mental Status, Dementia, and Anxiety. The facility's policy on abuse, neglect, and exploitation emphasized the need for staff to be aware of residents' care needs and behavioral symptoms. However, the lack of supervision in the dining room and the failure to separate residents with known behavioral issues contributed to the incident, highlighting a deficiency in the facility's ability to prevent abuse and ensure resident safety.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an incident of abuse to the State Agency in a timely manner for two residents involved in an altercation. On the evening of March 16, 2024, an LPN heard a commotion in the dining room and observed one resident grabbing another by the shirt, resulting in scratches and hits to the face, leaving multiple abrasions on the chest and face of the victim. The LPN intervened to stop the altercation, and the Director of Nursing, emergency contacts, and physician were notified. Both residents were separated and assessed for injuries, and the local police were contacted shortly after the incident. Despite the immediate actions taken to address the situation, the Nursing Home Administrator did not report the incident to the state agency until ten days later, on March 26, 2024. The facility's policy requires that any allegations involving abuse or resulting in serious bodily injury be reported within two hours of discovery. The delay in reporting this incident was acknowledged by the Nursing Home Administrator during an interview, confirming that the expectation was not met according to the facility's policy.
Failure to Monitor Weight for High-Risk Resident
Penalty
Summary
The facility failed to ensure proper weight monitoring for a resident identified as being at high nutrition risk. The resident, who has cerebral palsy, dysphagia, and moderate protein-calorie malnutrition, was observed receiving tube feeding. Despite being at high risk, the facility did not obtain an admission weight, nor did they record weekly weights during the resident's initial weeks at the facility. This lack of monitoring was confirmed by both the Registered Dietitian and the Director of Nursing, who acknowledged that the resident should have had documented weights upon admission and weekly thereafter for four weeks. The facility's policy on weight monitoring, dated March 27, 2024, specifies that weights should be recorded at the time obtained and that newly admitted residents should have their weight monitored weekly for four weeks. However, this policy was not followed for the resident in question, as evidenced by the absence of recorded weights during the critical initial period of residency. This oversight resulted in a potential delay in identifying any undesirable changes in the resident's weight status and compromised their nutritional status.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to dissatisfaction with meals. On the specified date, the resident was observed with a lunch tray that did not meet her preferences. Although she expressed a liking for vegetables and requested alternatives such as carrots and green beans, no meal alternative was offered. The resident reported not receiving the requested vegetables and was not informed of available food items that could be requested as alternatives. The Dietary Manager indicated that residents could order from an alternate menu, but this menu was only posted in the dining room and not provided to the resident. The resident's meal ticket noted a preference for vegetables, but no dislikes were listed. The Nursing Home Administrator acknowledged that residents should be aware of the always available menu, and there should have been follow-through on the resident's requests for specific vegetables. The facility did not provide any additional documentation or information before the end of the survey.
Infection Preventionist Absence in QAA Committee
Penalty
Summary
The facility failed to meet the requirement for having an Infection Preventionist (IP) as a member of the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) committee for three consecutive quarters. During a review of the QAA/QAPI quarterly meeting notes, it was found that the sign-in sheets for the meetings held in September 2023, January 2024, and May 2024 did not include a signature from an IP. The Nursing Home Administrator (NHA) explained that the previous NHA, who also served as the Director of Nursing (DON), was supposed to fulfill the IP role. However, the Business Manager and Human Resource Director were unable to verify the IP credentials for the previous Administrator and DON, as they could not be located in the records. Further investigation revealed that the current DON, who was expected to hold the IP certification, did not have it at the time of the last QAA meeting on May 15, 2024. The DON confirmed that the IP certification was only awarded on May 20, 2024, after the meeting had taken place. The facility's policy on QAPI, which was implemented on November 1, 2022, mandates that the QAA committee must include an IP among its interdisciplinary members. The absence of an IP in the committee for the specified quarters potentially impaired the facility's ability to effectively resolve infection control and prevention issues, affecting the quality of care for all 27 residents in the facility.
Facility Fails to Meet Space Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the required 80 square feet of space per bed in six of the 33 resident rooms, specifically rooms 2, 7, 10, 11, 12, and 14. Observations and record reviews revealed that room 2 had 283 square feet for 4 beds, room 7 had 218 square feet for 3 beds, room 10 had 225 square feet for 3 beds, room 11 had 215 square feet for 3 beds, room 12 had 154 square feet for 2 beds, and room 14 had 144 square feet for 2 beds. Despite these deficiencies, interviews with various residents did not reveal any specific complaints or health/safety concerns related to the space provided.
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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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