Notting Hill Of West Bloomfield
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bloomfield, Michigan.
- Location
- 6535 Drake Rd, West Bloomfield, Michigan 48322
- CMS Provider Number
- 235663
- Inspections on file
- 35
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Notting Hill Of West Bloomfield during CMS and state inspections, most recent first.
A resident with advanced dementia, osteoarthritis, and full dependence for ADLs sustained an acute, displaced spiral fracture of the distal humerus during morning care when a CNA was dressing the resident in a pull-over shirt. Night-shift staff reported no falls or incidents, and the resident, who previously had functional upper-extremity ROM and no contractures, was found with a swollen, painful, and deformed right arm during dressing. The CNA acknowledged the resident was wincing, resisting, and signaling for care to stop but continued dressing instead of stopping. ER and orthopedic evaluations described the fracture pattern as atypical and usually caused by significant trauma, a fall, or hard twisting, while the facility’s investigation concluded the cause was unknown and did not substantiate abuse. The DON did not obtain a witness statement from the prior day-shift LPN, and the record at the time of transfer lacked a full nursing assessment, pain assessment, change-of-condition assessment, and transfer form, while the facility’s incident policy addressed documentation of injuries of unknown origin but not their prevention.
Surveyors found that the facility failed to maintain an effective water management and infection control program, including control of Legionella and other waterborne pathogens. A hopper in the soiled laundry room produced discolored water, boiler temperatures were below the facility’s stated settings, and the Legionella plan lacked a flow diagram and current water management team activity. The AMS reported no active water management team, no involvement in the plan, no flushing logs, and exclusion of the laundry hopper from flushing routines, while the NHA acknowledged that water management meetings had not occurred as required. The infection control surveillance program was not continuous, line listings lacked key infection data and McGeer’s criteria, and requested lab and antibiotic rationale documentation for residents were unavailable, with the ICP reporting they were frequently used as a floor nurse and had not received needed support or additional training.
Surveyors found that the facility failed to honor resident mealtime and dining location preferences when multiple residents reported that the main dining room was frequently closed and never open on weekends, despite their desire to eat there to socialize and receive warm, complete meals. Residents stated that when they were served in their rooms, items they had selected on weekly menus were often missing, and soup and salad routinely offered in the dining room were not provided. The DON indicated that the Dining Manager (DM) decided when the dining room was open, and the DM acknowledged the dining room had been closed for several days due to equipment issues and remained closed on weekends as part of a post-COVID "plan" without an official written reopening plan. These practices conflicted with facility policies requiring support of resident choice regarding dining location and affirming residents’ freedom of choice in how they live and receive care.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with food debris and trash along hallway handrails, heavily soiled doors, damaged drywall, and exposed sharp metal in resident rooms. Several residents reported infrequent room cleaning, persistent urine on floors, foul-smelling heater filters, unrepaired leaking toilets, and broken toilet seats that had been reported weeks earlier. One resident had no toilet paper in their bathroom despite notifying CNAs and had to use paper towels, while other rooms had non-functional or inaccessible call systems. Observations also showed peeling drywall, leaking toilets with basins catching water, limited clean linens and disposable briefs in supply rooms, heaping soiled linen bins, and CNAs reporting frequent linen shortages that disrupted shower schedules. Work order logs lacked documentation of current environmental issues and did not reflect residents’ reported concerns, despite staff stating that supplies were adequate and that housekeeping was responsible for restocking resident rooms and bathrooms.
The facility failed to ensure nurse coverage for a hallway of resident rooms, leading to widespread missed medications and treatments for multiple residents. A resident with CHF and atrial fibrillation did not receive day-shift medications until late evening, and record review showed numerous missed medication doses and treatments for that resident and many others on the same unit. CNAs reported there was no nurse assigned to the hallway, that residents did not receive medications, and that many were in pain when they were changed without pain meds. Staffing records showed no nurse scheduled for the first floor despite a substantial census, and the DON later acknowledged possible miscommunication about nurse assignments and identified extensive missed medications on a facility report, in contrast to the facility’s own abuse/neglect policy defining neglect as failure to provide necessary care and services.
Surveyors found that medications and treatments were not administered according to physician orders or facility policy. Multiple residents reported delayed or missing morning medications, and MAR reviews showed 9:00 AM doses for several residents with complex cardiac and diabetic conditions were not documented as given, with no physician notification or progress notes. A nurse acknowledged not completing a heavy morning med pass and not informing administration or the physician. Additionally, two residents with intact cognition were observed with soiled, undated, or long‑unchanged dressings on the hand, arm, and knee, despite care plans and orders for scheduled wound care. TAR entries indicated treatments were completed on certain days, but the observed condition of the dressings and resident reports conflicted with this documentation, and required skin assessments and dressing dating were not consistently performed.
The facility failed to maintain sufficient nursing staff on all shifts, leading to prolonged call light response times and delayed medication administration and treatments. Multiple residents reported waiting from 20 minutes to over two hours for assistance, missing or receiving very late morning and evening medications, and observing staff talking at the nurses’ station while they waited. A resident described frequent 1–1.5 hour call light delays and late or next-morning administration of night medications when no nurse was available to relieve the day nurse. Another resident reported no nurse present until late morning on a recent Sunday, resulting in missed morning medications, while a family member stated their loved one stopped using the call light and fell when attempting to toilet independently. LPNs and the staffing coordinator confirmed ongoing nurse shortages, reduction in nurse numbers, elimination of a dedicated treatment nurse, and reliance on corporate PPD-based staffing without direct adjustment for resident acuity, contrary to the facility’s own policy requiring 24-hour nursing coverage and staffing based on resident needs.
The facility failed to maintain an effective antibiotic stewardship program when the ICP, who was hired for infection control, reported spending most of their time working as a floor nurse due to staffing shortages and could not consistently perform stewardship duties. The ICP described intended practices such as using McGeer's criteria, audits, and an infection screening tool, but review of infection control records showed missing documentation of resident lab results, clinicians' rationale for antibiotic use, and criteria supporting prescribed antibiotics. The ICP stated the program was only compliant for one month when staffing was adequate, and that requests for additional help and training from corporate were denied. When surveyors requested the antibiotic stewardship policy, no additional information was provided.
Two residents with existing pressure ulcers did not consistently receive or have documented the ordered wound care. One resident admitted with a Stage 3 heel ulcer reported missed every-other-day treatments and painful, overly tight wraps; TAR review showed multiple missed or undocumented Monday/Wednesday/Friday treatments, and the wound care nurse confirmed that a Kerlix wrap was used instead of the ordered border foam dressing and that required weekly wound photos were not obtained due to an uncharged camera. Another resident admitted with multiple pressure injuries, including a Stage 4 and an unstageable ulcer, had detailed twice-daily wound care orders on hospital discharge paperwork, but no corresponding physician wound orders or TAR documentation for several days after admission, and an early skin check documented "No skin issues" despite later same-day documentation of significant heel and coccyx ulcers. The ADON acknowledged that the admitting nurse failed to enter the wound care orders and that there was no documentation of wound care before the TAR entries began, contrary to the facility’s skin management policy.
Surveyors found that the facility’s medication error rate exceeded 5% after observing an RN administer a morning medication pass in which Duloxetine 60 mg, ordered to be given at bedtime for depression, was instead given in the morning, and Famotidine 20 mg, ordered once daily in the morning for GERD, was not observed being administered but was signed out as given on the MAR. These administration and documentation errors contributed to a calculated medication error rate of 6.45%.
Surveyors found that multiple opened and prepared food items in the kitchen, including sour cream, fruit, desserts, and salad dressings, were not labeled or dated as required by facility policy and food safety standards. Dietary staff confirmed these items should have been labeled and dated, and the deficiency had the potential to affect all residents receiving food from the kitchen.
A resident with a temporary Foley catheter developed a full-thickness penile wound due to excessive tension and trauma from the indwelling catheter. The injury, confirmed by wound care staff and a physician, was identified as ventral urethral erosion and required surgical evaluation. Facility leadership acknowledged the catheter as the cause of the injury.
Three residents with severe cognitive impairment and high risk for accidents were not adequately supervised, resulting in one resident sustaining fractures during a transfer, another ingesting a bleach sheet despite 1:1 supervision, and a third exiting through an alarmed door and descending a staircase. Staff were assigned to supervise multiple high-risk residents simultaneously, and lapses in supervision and lack of incident investigations contributed to these deficiencies.
A resident with multiple psychiatric diagnoses was not consistently offered or provided scheduled bathing, with documentation showing bathing was only offered four times in a month and provided twice, despite facility policy and the resident's stated needs and preferences. The DON confirmed the expectation for twice-weekly bathing and proper documentation, but could not provide evidence of compliance.
A resident with multiple chronic conditions did not receive scheduled and as-needed pain medications due to pharmacy delays, despite both morphine and oxycodone being available in the facility's back-up supply. Nursing staff did not access the back-up medications as required, leading to uncontrolled pain and a transfer to the emergency room for pain management. The facility's medication administration policy did not address procedures for pulling medications from the back-up supply.
A resident with multiple mental health diagnoses did not receive meals according to their documented food preferences, including double portions and cheese on eggs, and was repeatedly served food at temperatures below facility standards. Observations confirmed that meal tickets were not followed and food was not kept warm, as acknowledged by the kitchen manager.
Two residents were subjected to abuse and neglect by staff members. One resident was slapped by a CNA during an altercation, while another resident was neglected when their wheelchair was pushed into objects, causing potential harm. The facility's policies on abuse and neglect were not followed, leading to these deficiencies.
The facility's kitchen was found to have several sanitation deficiencies, including undated food items in the walk-in cooler, improper storage of utensils in dry storage, and a shelving unit with accumulated grease and debris. These issues were confirmed by the Dietary Manager and are not in compliance with the 2017 FDA Food Code.
The facility failed to provide privacy for Resident Council meetings, which were held in an open room frequently accessed by staff, leading to interruptions. Residents' grievances were not documented or addressed, and many were unaware of the grievance process. The Resident Council President often missed meetings due to lack of assistance, further hindering the council's effectiveness.
The facility failed to maintain a sanitary and homelike environment in several areas, including resident rooms, the central shower room, and dining areas. Observations revealed unkempt floors, dried food substances, and improper storage of personal items and cleaning supplies. The Housekeeping Director confirmed that housekeeping was responsible for these areas, but they had not been adequately cleaned, contrary to the facility's housekeeping policy.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents without proper investigation or intervention by the facility. The facility's documentation was incomplete, lacking staff interviews, root cause analyses, and notifications to the physician or responsible party. The Director of Nursing acknowledged the issues but could not provide further explanations or documentation.
The facility failed to provide sufficient nursing staff, leading to delayed care and lack of supervision for residents, including one with wandering behaviors and cognitive challenges. Despite a staffing plan requiring 16 licensed nurses and 24 nurse aides, actual staffing levels often fell short, resulting in inadequate supervision. A resident with Down syndrome and intellectual disabilities was observed wandering unsupervised, entering other residents' rooms, and displaying distress without staff intervention. The DON did not believe increased supervision was necessary, and the facility lacked documentation for certain dates, posing a risk to all residents.
The facility failed to ensure proper medication storage and labeling, with pills found on the floor and unsecured medication carts. A resident with severe cognitive impairment had unauthorized eye drops at bedside. COVID-19 Rapid Tests were stored unsecured, and staff were unaware of unlocked medication carts, violating facility policy.
The facility failed to implement effective infection control practices, including hand hygiene during medication administration and Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Observations showed a lack of appropriate signage and PPE for EBP, and multiple nurses did not perform hand hygiene before and after administering medications, despite the DON's confirmation of this requirement.
A resident with severe protein-calorie malnutrition and morbid obesity did not have a comprehensive nutritional care plan developed. The care plan was incomplete, lacking specific interventions, and there was conflicting documentation regarding nutritional monitoring. The RD did not perform the evaluation due to absence, and the facility's policy on nutritional documentation was not followed.
A resident with a history of hepatitis, hypertension, diabetes, and psychiatric conditions was found to have a deficiency in medication administration and documentation. The resident expressed concerns about a medicated lotion left uncovered at their bedside, which was not applied by the LPN as per the MAR. The LPN left the medication without confirming its application, and the resident was unaware of its purpose. The Nursing Home Administrator was informed but provided no further explanation.
The facility failed to provide timely incontinence care for three residents, leaving them wet for extended periods. One resident was left waiting for assistance despite requesting help, while another was found in wet sheets overnight. The residents expressed discomfort and upset due to the lack of care, and a CNA confirmed that such incidents were frequent. The residents required assistance with activities of daily living, as indicated by their care plans.
A resident with a history of nontraumatic subdural hemorrhage and other conditions reported skin itching and burning, suspecting an abscess. Despite informing the nursing staff, no action was taken, and the issue was not documented in weekly skin assessments. The Director of Nursing was unaware until informed by a surveyor, leading to a delayed response in addressing the resident's condition.
A resident with limited range of motion in their legs did not receive restorative therapy services after returning from a hospital stay, despite expressing a desire to continue therapy. The facility lacked a fully functioning restorative program and a restorative nurse to oversee it. The Director of Nursing acknowledged the oversight and the need for screening, but the resident's care plan did not reflect the need for restorative therapy, leading to a deficiency in care.
A facility failed to conduct a comprehensive nutritional assessment for a resident with significant nutritional needs following gastric sleeve surgery. Despite serious diagnoses, the care plan was incomplete, and there was no evidence of a comprehensive assessment by the RD. The RD was unaware of a STAT order for evaluation and did not complete the necessary documentation, leading to the deficiency.
A facility failed to document non-pharmacological interventions before administering PRN Alprazolam to a resident with severe cognitive impairment and multiple diagnoses. The medication was given multiple times without proper documentation, and the behaviors recorded did not match the times of administration. The DON acknowledged the lack of documentation and questioned the appropriateness of the medication order.
A facility failed to provide timely radiology services for a resident who fell and was ordered an X-ray for their left shoulder. Despite the physician's order, the X-ray was not completed until after the survey identified the issue. The resident, with a history of neurological conditions, reported significant shoulder pain. The DON stated X-rays should be completed within 24 hours, but there was no policy in place to ensure this.
A resident with a history of influenza and pneumonia consented to receive pneumococcal and influenza vaccines through their daughter, who served as a translator. However, the facility did not administer the vaccines, and the orders were discontinued by the physician without documented rationale. The Infection Control Preventionist confirmed the oversight, and there was no follow-up with the resident or their daughter, who believed the vaccines had been given.
A resident with a history of diabetes and peripheral vascular disease experienced a worsening diabetic ulcer due to the facility's failure to timely assess and treat the condition. Despite documentation inconsistencies and delays in treatment orders, the ulcer progressed, resulting in a hospital transfer and amputation of the resident's left great toe. Interviews with facility staff revealed issues with wound management and documentation, highlighting a lack of adherence to the facility's skin management policy.
A strong, putrid odor was detected in the hallway near the main dining room, attributed to a dish machine issue. Despite acknowledgment from several staff members, including the RD and Maintenance Assistant, the source of the odor remained unidentified for weeks. The Administrator was unable to detect the odor, while the dish room itself did not contain the odor, only the hallway did.
A registered nurse (RN) failed to administer medications to three residents, as confirmed by surveillance footage and resident reports. Despite documentation indicating medications were given, the RN did not enter the residents' rooms during the administration period. Interviews and time card discrepancies further highlighted the neglect in care.
A nurse at the facility, referred to as Nurse A, was found to be working with a suspended LPN license. Despite the suspension in February 2024, Nurse A continued to work shifts, including a recent night shift. The facility's HR staff had not reviewed all nursing licenses, and the DON and Administrator were unaware of the suspension until the investigation. The facility's policy required current licenses for all staff, but this was not followed for Nurse A.
Failure to Prevent Injury of Unknown Origin During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to prevent an injury of unknown origin and to ensure adequate supervision and accident hazard prevention for a cognitively impaired resident who sustained a right humerus fracture during care. The resident had Alzheimer’s disease, dementia, kidney disease, anxiety, and depression, was severely cognitively impaired, and was dependent for dressing, bed mobility, toileting, transfers, and largely for eating. Prior assessments and therapy records showed no documented contractures and upper extremity range of motion within normal limits, with the resident able to assist with feeding when items were placed in the hand. The resident was not on pain medication prior to the incident and had no documented pain on the most recent MDS. On the night and early morning in question, staff working the night shift reported no falls or incidents and stated the resident slept through the night without signs of distress. At approximately 5:00–5:15 a.m., a CNA entered the room to provide morning care and dress the resident, who was scheduled to be gotten up and dressed on the midnight shift. The CNA reported the resident was wearing a pull-over pajama top and was changed into another pull-over shirt. During dressing, the CNA noted the resident’s right arm appeared swollen and limp, and that when the resident attempted to help push the right arm through the sleeve, the resident expressed pain and the arm became limp. The CNA acknowledged that the resident was wincing, waving for care to stop, and more verbal than usual, but the CNA continued dressing instead of stopping care, later stating they should have stopped when resistance and increased pain were observed. Subsequent nursing assessment documented that the resident’s upper arm was swollen, abnormal in appearance, and misaligned at the elbow joint, suspicious for a fracture, with pain on minimal movement. The resident was sent to the ER, where imaging showed a displaced, angulated, spiral fracture of the distal humerus, described as atypical and typically resulting from significant trauma, a fall, or a hard twisting motion. Hospital and orthopedic records characterized the injury as an acute, unstable fracture, presumed to be from an unwitnessed fall or twisting trauma, while the facility’s internal investigation concluded the exact cause was unknown and did not substantiate abuse or neglect. The DON, who led the investigation, did not obtain a witness statement from the day-shift LPN who had cared for the resident before the transfer, and the medical record lacked a complete nursing assessment, pain assessment, change-of-condition assessment, and transfer form at the time of the resident’s transfer. The facility’s Incidents and Accidents policy addressed documentation and reporting of injuries of unknown origin but did not address prevention of such injuries.
Failure to Maintain Effective Water Management and Infection Control Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective water management and infection prevention and control program, including control of Legionella and other opportunistic premise plumbing pathogens. Surveyors observed a functional hopper in the soiled laundry sorting room that produced discolored water for several seconds before running clear. In the boiler room, one boiler was observed at 128°F and the second at 122°F, despite facility documentation indicating usual boiler settings of 150°F and CDC guidance in the facility’s materials stating that hot water should be stored above 140°F and recirculated hot water should not fall below 120°F. The facility’s Legionella Environmental Plan binder lacked a flow diagram and written description of how water travels through the building, despite the written policy requiring description of building water systems using flow diagrams and written descriptions. The Assistant Maintenance Supervisor (AMS) reported that the Maintenance Director had left suddenly two weeks earlier and that there was no water management team to their knowledge. The AMS stated they were not involved in the water management plan, were unsure of the Maintenance Director’s responsibilities regarding the plan, and that flushing of tubs, hoppers, and eyewash stations was done weekly based on TELS notifications, without keeping logs. The AMS also indicated that the hopper in the laundry room was not part of their flushing routine. The Nursing Home Administrator (NHA) stated that the water management team previously consisted of the NHA, DON, Infection Preventionist, and Maintenance Director, and that the AMS was now assuming those responsibilities. When asked about formal water management meetings, the NHA acknowledged that the team needed to meet and did not dispute that the last documented minutes were from 2024, with no documentation of a 2025 meeting and no additional water management documentation beyond what was in the binder. The facility’s infection control surveillance program was also found to be deficient. The Infection Control Preventionist (ICP) reported no recent outbreaks or trending infections but acknowledged that the surveillance program was not ongoing or continuous and was a month behind. The line listing lacked key information such as type of infection, duration of treatment, and location, and McGeer’s criteria were not provided or implemented. When surveyors requested laboratory results, clinicians’ rationale for antibiotic use, and documentation of McGeer’s criteria for several residents, the requested materials were not available. The ICP stated they had been working as a floor nurse due to staffing shortages, leaving the infection control program noncompliant except for one month when staffing allowed them to focus on their hired role, and reported they had not been offered assistance or support and had been denied additional help and training from corporate staff after orientation. No additional information was provided at survey exit.
Failure to Honor Resident Mealtime and Dining Location Preferences
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ mealtime preferences and support resident choice regarding dining location and meal service. During an observation of the main dining room, surveyors noted residents interacting and staff taking meal orders in a restaurant-style format. However, in a confidential meeting with eight residents who usually attended resident council, six reported that the main dining room was frequently closed and not open at all on weekends. These residents stated they preferred eating in the dining room because it allowed them to get out of their rooms, socialize, receive warm meals, and obtain all menu items they had selected. They reported that when they received meal trays in their rooms during dining room closures, items were often missing despite their pre-completed weekly menu selections, and that soup and salad routinely offered in the dining room were not offered when they ate in their rooms. Residents reported that these dining restrictions had been in place for a long time and expressed frustration over their loss of choice to eat in the main dining room, with several stating they believed the dining room was only opened that week because the State Agency was present. The DON stated that decisions about opening or closing the main dining room were made by the Dining Manager (DM). The DM reported that the dining room would only close for emergencies such as an outbreak, but also acknowledged it had been closed for four or five days earlier in the month due to a fuse box issue with the dish machine. The DM further stated the main dining room was not open on weekends, explaining this was their plan since COVID-related dining room shutdowns, and that there was no official written plan for reopening. These practices conflicted with facility policies stating that residents would be interviewed about their preference to eat in the dining room or their room and that residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.
Environmental Cleanliness, Maintenance, and Supply Failures Affect Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident rooms and common areas, as well as failures in basic housekeeping, maintenance response, and supply availability. Surveyor observations over several days showed food debris, used tissues, and other trash accumulated along the inner bottom portions of handrails throughout a second-floor hallway, and multiple resident room and private dining room doors were heavily soiled with dirt, debris, and dried liquid splatter. One resident’s room had a corner wall with missing drywall crumbled onto the floor and an exposed metal brace with sharp edges, and the resident’s dresser had a thick layer of dust across the top. In another room, drywall was peeling away from the walls in multiple areas, exposing the underlying cardboard, and this condition persisted on re-observation two days later. During a confidential resident council interview, several residents reported housekeeping and maintenance concerns. One resident stated their carpet was so dirty that their wheelchair wheels turned their hands black when propelling, and another reported their room was only cleaned twice a week. A resident described a roommate who used a urinal and frequently missed, leaving urine on the floor and between the room divider that remained for a long time and smelled strongly of urine. Other residents reported a thick, foul-smelling heater filter, a leaking toilet that required the resident to dump collected water every night, and a broken toilet seat that had been reported about a month earlier without repair. One resident reported having no toilet paper in their bathroom since the previous night despite informing two CNAs, resulting in the resident using paper towels to clean themselves, which caused discomfort; the bathroom was observed to have no toilet paper. Additional observations showed environmental and safety issues related to call systems and room conditions. In one bathroom, the call light pull cord was wrapped around a grab bar, making it non-functional for the resident. In another room, the resident’s call button was on the floor and out of reach. A room with a leaking toilet had a small plastic basin under the pipes that was nearly full of water; when the toilet was flushed, the leak worsened. Another room had a loose toilet seat that slid easily from side to side. The facility’s maintenance worker later confirmed that the peeling drywall in one resident’s room would need repair and painting and stated they had not been made aware of the issue, despite the facility having a notification system that should have been used. The facility’s housekeeping and laundry operations also contributed to the deficiency. The Director of Housekeeping and Laundry acknowledged staffing issues and that housekeeping staff did not work weekends, resulting in accumulated housekeeping concerns by Monday. The director confirmed the observed debris along the hallway handrails and the damaged wall and debris in the resident’s room. Laundry observations showed both washers and dryers running and large amounts of clean linens awaiting folding, with housekeeping staff pulled from their usual duties to help catch up on laundry. CNAs reported frequent shortages of clean linens, particularly towels, which disrupted shower schedules. Clean linen rooms on both floors were observed with limited supplies of washcloths, bath towels, and disposable briefs in certain sizes, while soiled linen rooms contained heaping, unemptied bins of bagged soiled linens and personal laundry. Record review of the facility’s work order log from a several-month period showed only completed items, with no documentation of existing environmental concerns, no dates of when issues were reported, and no dates of correction. The log did not include any of the specific resident-reported concerns such as leaks, broken toilet seats, or wall damage. Staff interviews indicated that housekeeping was responsible for restocking toilet paper in resident rooms and public restrooms, including on weekends, and that central supply maintained adequate stock of linens, briefs, and toilet paper. However, the observed lack of toilet paper in at least one resident’s bathroom, the low levels of linens and briefs in clean supply rooms, and the reported disruptions to shower schedules due to linen shortages demonstrated that supplies were not consistently delivered to resident care areas as needed, contrary to the facility’s housekeeping policy requiring daily cleaning of surfaces and regular carpet care, as well as prompt response to visible soiling and spills.
Failure to Assign Nurse Coverage Resulting in Widespread Missed Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not ensuring that a nurse was assigned to a block of rooms (125–147, Orchard Lake hallway) during a day shift, resulting in missed medications and treatments for multiple residents. A family member reported that one resident did not receive any day-shift medications until approximately 9:00 p.m., and stated that a nurse told them no nurse was assigned to that hallway and that other nurses could not assume responsibility without risking their licenses due to high resident loads. Review of the medical record for this resident, who had been admitted with diagnoses including congestive heart failure and atrial fibrillation and required assistance with most activities of daily living per the MDS, showed approximately 16 missed doses of medications/supplements and three missed urostomy treatment opportunities on that day. Further review of the MARs and TARs for 17 additional residents on the same unit revealed numerous missed medications and treatments during the same day shift. The missed items included, for example, six medications for one resident; 10 medications for another; six medications and eight treatments for another; and up to 18 medications and one treatment for another resident. Additional residents had between three and 17 missed medications each, with several also missing one to four treatments. Certified nursing assistants assigned to the Orchard Lake rooms confirmed that there was no nurse assigned to those rooms during the day shift and reported that, while a nurse from another hallway occasionally came over, they believed residents did not receive medications and that many residents were in pain because they were changed without pain medications. Review of the facility’s nurse staffing assignment for the day in question showed no nurse scheduled to work the first floor, which had a census of 38 residents, while CNAs were assigned to the Orchard Lake rooms. The DON stated they were unaware that the hallway had no assigned nurse and explained that with a census of 86, three nurses should have divided the building, with one nurse covering a split assignment between floors. The DON indicated there may have been a miscommunication regarding nursing assignments and reported that a missed medication report for that day generated 15 pages of residents with missed medications. A nurse interviewed by phone described poor staffing, noted that usually four nurses were scheduled (two per floor), and acknowledged that on a few occasions only three nurses were scheduled, stating they had informed the facility they could not safely split the building in that manner. The facility’s Abuse Prohibition Policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress and included alleged violations where the facility demonstrates indifference or disregard for resident care, comfort, or safety resulting in such outcomes.
Untimely Medication Administration and Poor Wound/Dressing Management
Penalty
Summary
Surveyors identified that medications were not administered according to physician orders, resident preferences, and facility policy for multiple residents. During a confidential resident council interview with eight residents, five reported concerns about delayed medication administration, including the absence of a nurse on their wing until midnight and not receiving scheduled morning medications such as a pain patch due between 9:00 AM and 10:00 AM. At the time of the interview, three additional residents also reported they had not yet received their 9:00 AM medications. Review of Medication Administration Records (MARs) on 3/24/26 at 12:40 PM showed that several residents had no documentation of their scheduled 9:00 AM medications or treatments being administered, and there were no progress notes or physician notifications regarding missed or late doses. Record review for one resident with diagnoses including atrial fibrillation, congestive heart failure, diabetes, and chronic kidney disease showed multiple daily medications such as Eliquis, furosemide, lisinopril, and potassium chloride ordered, but the 9:00 AM MAR entries for that day were blank. Another resident with acute and chronic respiratory failure, COPD, heart failure, atrial fibrillation, and multiple cardiac and anticoagulant medications had orders for time-specific doses at 9:00 AM and 9:00 PM, including apixaban, hydralazine, sacubitril-valsartan, and isosorbide dinitrate, yet the 9:00 AM medications were not documented as given by 12:40 PM. A third resident with heart failure, COPD, diabetes, hepatitis C, and neuropathy had multiple scheduled medications and sliding scale insulin ordered before meals and at bedtime; documentation showed the last blood sugar check and insulin administration at 7:00 AM, with no documentation of a blood sugar check before the noon meal despite the resident already being in the dining room and a history of frequent sliding scale insulin coverage before meals. A fourth resident with dementia, hypertension, diabetes, hyperlipidemia, and anemia had several daily medications and nutritional supplements ordered at 9:00 AM and 5:00 PM, but the 9:00 AM medications were not documented as administered. When interviewed, the nurse assigned to the unit stated the morning medication pass was not completed due to a heavy med pass and acknowledged not notifying administration or the physician about the delays. The facility’s Medication Administration policy required medications to be given within 60 minutes of the scheduled time, but the policy did not address late or missed medications, and the DON could not explain the lack of documentation or notifications. Surveyors also found failures in wound and dressing management for two residents. One resident with intact cognition and diagnoses including heart failure, peripheral vascular disease, and diabetes had a right knee abrasion care plan and a physician order to cleanse the abrasion and apply triple antibiotic ointment with a border gauze dressing on Monday, Wednesday, Friday, and as needed. On observation, the resident’s right leg dressing was visibly soiled, saturated, and dated 3/17, and the resident reported no one had offered to change it since that date. The Treatment Administration Record (TAR) showed the treatment documented as completed on 3/18 and 3/20 by the nurse manager, but the observed condition of the dressing and the resident’s report conflicted with that documentation. In another case, a cognitively intact resident admitted with pleural effusion, sepsis, and malnutrition was observed with an undated, worn bandage on the right hand that the resident stated had been applied at an outside appointment on 3/17/26 and had not been assessed or changed by facility staff. The same resident also had an undated foam border dressing on the left outer arm, which the resident reported had not been changed for a couple of days, despite a care plan requiring weekly head-to-toe skin assessments and a physician order for right arm abrasion care every Monday, Wednesday, Friday, and as needed. The TAR showed the right arm treatment marked as completed on 3/20 and left blank on 3/23, and a skin check dated 3/21 documented no skin issues. When the DON later removed the hand dressing, an old, soiled dressing was revealed over a scabbed area, and the DON confirmed that dressings should be dated and that nurses were expected to assess any dressing without an order and obtain appropriate treatment orders. The facility’s Skin Management policy required licensed nurses to monitor, evaluate, and document changes in skin condition, including dressings and surrounding skin, and to notify the resident, responsible party, practitioner, DON/designee, and treatment team when a new area of skin impairment was identified. Despite these requirements, the observations and record reviews showed that dressings were left in place for extended periods without being changed, were not dated, and were not consistently assessed or documented. In addition, there were discrepancies between TAR documentation and the actual condition of residents’ dressings, with one nurse manager having documented treatments as completed on dates when the dressing remained unchanged and soiled. These actions and inactions led to deficiencies in ensuring medications and treatments were provided according to physician orders, resident needs, and facility policies.
Failure to Maintain Sufficient Nursing Staff Leading to Delayed Care and Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet resident needs, resulting in prolonged call light response times and delays in medication administration and treatments. During a confidential resident council interview with eight residents, all participants reported concerns about staffing and response times. Residents stated that at times there was no nurse on their wing until midnight, that the day nurse had to stay late, and that morning medications and pain patches due between 9:00 AM and 10:00 AM were not administered on time. Multiple residents reported waiting from 20 minutes up to two hours for call lights to be answered, and described going to the nurses’ station to find staff talking and laughing while they were still waiting for assistance. Individual resident and family interviews further detailed the impact of inadequate staffing. One resident reported that call light responses averaged 1 to 1.5 hours and that there were also insufficient housekeeping and laundry staff, resulting in rooms being cleaned only every other or third day and laundry not being returned as expected. The same resident reported that on some occasions there was no nurse to relieve the day nurse, causing evening medications to be given very late or not until the next morning. Another resident reported that on a recent Sunday there was no nurse available until 11:00 AM, causing them to miss their morning medications, and stated that staffing had worsened since the beginning of the year, with only one nursing aide assigned to an entire hall. A third resident reported long call light response times, especially on the afternoon shift, and a family member reported that their loved one had stopped using the call light because there were not enough staff to answer it and had fallen over a weekend while attempting to go to the bathroom. Staff interviews and facility documentation confirmed ongoing staffing shortages and practices that did not ensure adequate nurse coverage. An LPN reported that staffing had declined from three nurses on the first floor to two nurses and four to five CNAs, which they felt was not enough to meet resident needs, leading to treatments being done late or not at all after the treatment nurse position was eliminated and floor nurses assumed all treatments. Another LPN stated that staffing had been poor, that usually four nurses were scheduled for the building, and that on some occasions only three nurses were scheduled, which they felt could not safely cover both floors. The staffing coordinator acknowledged that the building was short staffed, that about five nurses had recently resigned, and that the facility did not permit the use of agency or PRN nurses to fill gaps. The coordinator stated that staffing was based on PPD levels set by corporate, without directly incorporating resident acuity, and that nursing managers were expected to adjust for acuity. The facility’s own nursing staffing policy required 24-hour nursing services, a licensed nurse on each shift, and staffing based on resident number, acuity, and diagnoses, but the reported practices and outcomes showed these standards were not consistently met.
Failure to Maintain an Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that promotes appropriate antibiotic use and includes a system of monitoring. During an interview, the ICP stated that their role included ensuring residents met McGeer's criteria for antibiotic use, confirming staff followed protocols and procedures, educating staff on infection control policies, and using audits and an infection screening tool to determine if residents met criteria for antibiotics. The ICP reported they began the position in November 2025 and were hired specifically for infection control. However, the ICP explained that due to staffing shortages they were frequently assigned to work as a floor nurse and could only perform infection control duties when time allowed. Review of the infection control books showed that requested information, including specific resident lab results, clinicians' rationale for antibiotic use, and documentation of McGeer's criteria supporting prescribed antibiotics, was not available. The ICP acknowledged that the program was not compliant except for one month when staffing was adequate. The ICP also reported that they had requested additional help and training from corporate staff but were denied, and that they had functioned more as a floor nurse than an ICP. When the antibiotic stewardship policy was requested, no additional information was provided.
Failure to Provide and Document Ordered Pressure Ulcer Treatments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pressure ulcer treatments were obtained, carried out as ordered, provided in a timely manner, and accurately documented for two residents with pressure injuries. One resident was admitted with a Stage 3 pressure ulcer and a surgical wound, and another was admitted with multiple pressure injuries including a Stage 4 and an unstageable ulcer. For the first resident, the MDS showed admission with a Stage 3 pressure ulcer on the right heel. The resident reported that wound care was supposed to be done every other day without exception, but stated that treatments were sometimes missed and that the leg wrap was often applied too tightly, causing pain. The resident specifically reported missing a scheduled treatment on a Friday and showed the surveyor a wrap that hurt. Record review for this resident’s March Treatment Administration Records (TARs) showed multiple missed or undocumented wound treatments despite active physician orders. An order dated early in the month directed cleansing the right heel with normal saline, applying collagen, and covering with ABD pad and Kerlix wrap on Monday, Wednesday, and Friday. The TAR showed a blank, unexplained box for a Wednesday treatment and another blank for a Friday treatment when the order was discharged that same day. A subsequent order to cleanse with normal saline, apply collagen, and cover with border gauze on Monday, Wednesday, and Friday also showed missing treatments on a Wednesday and Friday, with only Saturday initialed as completed. Review of all March TAR entries confirmed that wound treatments were not documented as completed on the identified dates. The facility’s wound care nurse later acknowledged understanding the concern about missed treatments and stated that at least one treatment had been done but not documented. The nurse also confirmed that the correct treatment per current orders was a border foam dressing, not a Kerlix wrap, and that Kerlix had been used instead of the ordered border dressing. The same resident also reported that on a later date the wound had worsened because the wrong dressing was used, stating that gauze was used instead of a bandage and that the wound bled more and appeared larger when the dressing was removed by the nurse and physician. The wound care nurse confirmed that the order called for a border foam dressing and not a Kerlix wrap, and that Kerlix was a rolled gauze wrap used for cushioning or compression rather than as the primary ordered dressing. The nurse further reported that the facility’s standard was to obtain wound photos every seven days, but no photo was taken because the camera battery had not been charged while the nurse was off work. The surveyor was unable to observe the resident’s scheduled wound care because it was completed earlier in the day than arranged, and the Nursing Home Administrator later accepted responsibility for the missed observation. For the second resident, who was admitted with sepsis, atrial fibrillation, chronic kidney disease, and multiple pressure injuries, the MDS documented one Stage 4 and one unstageable pressure ulcer on admission. The admission nursing evaluation noted skin impairment to both heels and the sacrum, and an admission nurse’s note described wounds to both heels and an open wound to the coccyx, with measurements to be obtained per wound care protocol and dressings in place per hospital discharge orders. The hospital discharge paperwork contained detailed wound care orders for the left buttock, coccyx to right buttock, left heel, and right heel, all to be treated twice daily. However, the facility’s physician orders contained no wound treatment orders until several days after admission, and the TAR showed no documentation of wound care until the date after those orders were entered. A skin check entry for this second resident dated several days after admission documented “No skin issues,” while a separate skin/wound entry later that same morning identified a left heel unstageable pressure ulcer and a coccyx Stage 4 pressure ulcer with specific measurements. During interview, the ADON, who had been the wound care coordinator, stated that the resident was admitted on a Saturday and that the admitting nurse did not enter the wound treatment orders from the hospital discharge paperwork. The ADON confirmed that wound care orders from the hospital should be entered the same way as medication orders and acknowledged that there was no documentation of wound care provided before the TAR entries began. The facility’s Skin Management policy required that residents admitted with skin impairment have appropriate interventions implemented, a physician’s order for treatment, and documentation of wound location, measurements, and characteristics, as well as photos unless refused, which contrasted with the gaps in orders, documentation, and initial assessments identified in the record review for this resident.
Medication Administration and Documentation Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During a medication pass observed at 9:18 AM, a registered nurse administered multiple medications, including Lasix 20 mg, a multivitamin, MiraLAX 17 g, Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125 mg, vitamin B12, and lisinopril 5 mg. A subsequent review of the medication administration record at 12:38 PM revealed that Duloxetine 60 mg, ordered as a delayed-release capsule to be given by mouth at bedtime for depression, was instead administered during the morning medication pass. The review also showed an active order for Famotidine 20 mg by mouth once daily in the morning for GERD, which was not observed being administered during the medication pass but was documented on the medication administration record as having been given. These observed discrepancies between physician orders, actual medication administration times, and documentation on the medication administration record constituted medication errors that contributed to the facility’s medication error rate exceeding the 5% threshold.
Failure to Label and Date Opened and Prepared Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items in the kitchen were properly labeled and dated when opened or prepared. During an inspection of the kitchen's refrigerators and freezer, multiple items were found without required labeling or dating, including two opened containers of sour cream, trays of prepared fruit cups and sliced pears, a tray of sweet potato pie slices, a tray of dessert with whipped topping, and opened containers of ranch and Italian salad dressings. The dietary aide present confirmed that these items should have been labeled and dated according to facility policy and standard food safety practices. Further interviews with the Dietary Manager revealed that the facility's process required all food items to be labeled and dated before being placed in the refrigerator, and that prepared fruits and desserts were to be labeled and discarded within three days. Review of facility policies and storage charts confirmed these requirements, specifying timeframes for labeling and discarding various food items. The failure to label and date these food items had the potential to affect all residents consuming food from the kitchen.
Failure to Prevent Catheter-Related Urethral Injury
Penalty
Summary
A resident with a history of urinary retention and sacral wound infections was admitted with a temporary indwelling Foley catheter. The resident was cognitively intact and required ongoing medical and wound care. During the course of care, the resident developed a full-thickness wound on the penis, identified as a medical device-related injury associated with the indwelling catheter. Clinical documentation and wound care notes described the wound as having significant measurements and fresh blood drainage, with the wound bed showing 100% granulation. The injury was confirmed by both wound care staff and a physician, who attributed the trauma to the catheter. Further review and consultation with a urologist revealed that the resident had developed ventral urethral erosion, a rare but serious complication often caused by prolonged catheter tension, resulting in a partial or full-thickness wound of the urethra. The injury was significant enough to require evaluation for surgical correction. Facility leadership, including the DON and IDON, acknowledged that the injury was related to the urinary catheter and confirmed the findings with photographic evidence. The incident was discussed with the Nursing Home Administrator during the exit interview.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents and falls for three residents. One resident with severe cognitive impairment and multiple diagnoses was being prepared for transfer to a shower chair by a CNA who was waiting for a second staff member to assist. The CNA sat the resident on the side of the bed with a walker in place and turned away to respond to another resident's question. During this time, the resident slid off the bed and sustained fractures to both legs. Documentation confirmed the injuries and the sequence of events, and the Director of Nursing acknowledged the deficient practice. Another resident, also with severe dementia and a history of wandering and ingesting non-food items, was assigned 1:1 supervision due to being a fall risk and exhibiting unsafe behaviors. Despite this, the resident was found sucking on a bleach sheet, requiring intervention from poison control. Staff assignment records showed that one CNA was responsible for supervising both this resident and his roommate, who also required close supervision. Staff interviews revealed that it was very difficult to supervise both residents simultaneously, and that lapses in attention allowed the resident to access hazardous items. The roommate, who had dementia and a history of wandering and exit-seeking behaviors, was also at risk for falls and elopement. Despite care plans indicating these risks, the resident was able to exit through an alarmed door and go down a flight of stairs without staff intervention. There was no investigation documented for this incident, and staff confirmed that supervision was not consistently provided as required. The facility did not provide incident reports or investigations for some of these events, and staff interviews confirmed that supervision protocols were not adequately followed.
Failure to Provide Regularly Scheduled Bathing
Penalty
Summary
The facility failed to ensure that a resident was offered and provided regularly scheduled bathing as required. The resident reported that staff often missed their scheduled showers and, if they declined a shower at the offered time, staff did not return to offer it again later. The resident stated that they were only bathed about once a week, despite needing more frequent bathing due to sweating and personal preference. The resident also indicated a preference for showers in the afternoon or evening, which was not accommodated. A review of the resident's medical record showed that bathing was only documented as offered four times in the previous 30 days, with only two instances where bathing was actually provided. There was no documentation to support that bathing was offered at least twice weekly as required. The DON confirmed that showers should be offered at least twice weekly and that all offerings should be documented, but was unable to provide additional documentation to show compliance. Facility policy stated that residents should receive necessary assistance to maintain personal hygiene, but there was no evidence this was consistently done for the resident in question.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
The facility failed to ensure timely administration and refilling of pain medications for a resident with multiple diagnoses, including morbid obesity, diabetes, peripheral vascular disease, and depression. The resident experienced uncontrolled pain and elevated blood pressure after not receiving scheduled doses of morphine due to a pharmacy shipment delay. Documentation showed that the last dose of morphine was administered in the morning, and subsequent scheduled doses were not given because the medication was not available. Additionally, there was a significant delay in administering as-needed oxycodone, with nearly twelve hours between doses, despite the resident's ongoing pain. Progress notes and medication administration records confirmed that both morphine and oxycodone were available in the facility's back-up medication supply at the time, but were not pulled or administered as per physician orders. Interviews with the Director of Nursing revealed that nurses are expected to check and pull medications from the back-up supply when a resident runs out, especially for controlled substances, but this was not done. The facility's provided medication administration policy did not address procedures for accessing the back-up supply, contributing to the failure to provide appropriate pain management, which resulted in the resident being transferred to the emergency room for pain control.
Failure to Honor Food Preferences and Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to honor a resident's food preferences and ensure meals were served at safe and appetizing temperatures. During observation, a resident reported that their meal tickets were repeatedly incorrect, resulting in not receiving double portions or cheese on their eggs as requested. The resident also stated that the food was consistently cold and unpalatable. Direct observation confirmed that the breakfast tray did not match the resident's documented preferences, and the food was not warm. Review of the meal ticket corroborated that the resident was supposed to receive double portions with cheese, which was not provided. Further observations during lunch revealed that the resident's tray again did not include the required double portions, and food temperatures were below the standards reported by the kitchen manager. The kitchen manager acknowledged issues with staff reading meal tickets correctly and noted that food items were not at the appropriate temperatures when served. The resident's medical record indicated multiple mental health diagnoses, and facility policy required that food preferences be identified and honored on tray tickets, which was not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect by staff members. One resident, identified as R901, was forcefully slapped in the face by a Certified Nursing Assistant (CNA A) after an altercation where the resident was resistive while being wheeled down the hallway. The incident was captured on video, which showed CNA A slapping the resident while another staff member, Nurse B, was having their hair pulled by the resident. The facility's investigation confirmed the abuse, and the CNA was terminated following the incident. Another resident, R902, experienced neglect when Nurse D pushed their wheelchair into a medication cart and a metal doorframe, causing the resident to flinch. Nurse D did not acknowledge the incident and left the resident unattended while they accessed the medication cart. The resident, who had severe cognitive impairments and a history of wandering, was not properly monitored, leading to potential harm. Nurse D was observed to be unaware of the resident's name and was dismissive when approached about the incident. The facility's policies on abuse and neglect were not adhered to, as evidenced by the incidents involving R901 and R902. The facility's failure to protect these residents from harm and ensure their safety resulted in physical abuse and neglect. The incidents highlight a lack of adequate staff training and awareness regarding resident care and safety protocols.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour with the Dietary Manager (DM) Q. In the walk-in cooler, there were several undated food items, including a container of salad, a bag of diced chicken, and a bag of polish sausage. DM Q confirmed that these items should have been dated according to the 2017 FDA Food Code, which requires ready-to-eat, potentially hazardous food to be clearly marked with a date if held for more than 24 hours. This oversight in food labeling could potentially affect all residents consuming food from the kitchen. Additionally, in the dry storage room, scoops and Styrofoam bowls were improperly stored inside bins with their handles resting in the sugar, thickener, and corn starch. DM Q acknowledged that this was not the correct storage method. Furthermore, a shelving unit next to the oven, used for storing clean pots, was found to have a heavy accumulation of grease and food debris. DM Q mentioned that thorough cleaning is usually done on weekends, indicating a lapse in maintaining cleanliness as per the FDA Food Code requirements for nonfood-contact surfaces.
Lack of Privacy and Grievance Follow-Up in Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate privacy for Resident Council meetings, as observed during a survey. The meetings were typically held in the Piano Room, which lacked doors and was frequently accessed by staff, leading to interruptions and a lack of privacy. Residents expressed dissatisfaction with the meeting space, noting that staff ignored signs indicating a meeting was in progress and continued to enter the room. This lack of privacy hindered residents' ability to discuss their concerns freely. Additionally, the facility did not adequately address grievances raised during these meetings. Residents reported that their concerns, such as long call light response times and staff attitudes, were not followed up on. Many residents were unaware of the grievance process, with only two out of thirteen knowing about the existence of grievance forms. The facility's Grievance Officer, the Nursing Home Administrator, confirmed that no grievance forms had been filed in the past five months, indicating a failure to document and address resident concerns. The Resident Council President, who was responsible for leading the meetings, was often unable to attend due to not being informed or assisted in getting to the meetings. This further contributed to the residents' feeling that their concerns were not being taken seriously. The facility's policy required that a private space be provided for meetings and that grievances be documented and addressed, but these procedures were not followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in several residential common areas, including the central shower room, dining areas, and specific resident rooms. Observations revealed unkempt carpeted floors with debris, sticky ring marks on tiled floors, and dried food substances on walls and doors. In one resident room, dried brown tube feed was found on a dispensing machine and surrounding areas, while another room had a moderate pile of a cakelike substance on the floor. The central shower room had visibly soiled floors, chipped tiles, and non-functional lighting, with various personal items and cleaning supplies improperly stored. The common areas, such as the second-floor sitting area and the Piano Room, were observed with dust, unkempt tables, and dead insects on windowsills. The first-floor dining area had dead insects, webs, and stained tablecloths. During a tour with the Housekeeping Director, it was confirmed that housekeeping was responsible for maintaining these areas, but they had not been adequately cleaned. The facility's housekeeping policy, dated February 2023, emphasized the importance of maintaining a clean healthcare environment, but the observations indicated a failure to adhere to these standards.
Inadequate Fall Prevention and Documentation for Resident
Penalty
Summary
The facility failed to ensure timely and complete assessments and investigations into multiple falls experienced by a resident, identified as R85, who was at risk for fall-related injuries due to conditions such as hemiplegia, hemiparesis, and vascular dementia. The resident had a history of severe cognitive impairment and had experienced multiple falls, some resulting in injury, since admission. Despite these risks, the facility did not adequately document or investigate the falls, nor did they implement appropriate interventions to prevent future incidents. Observations and record reviews revealed that R85 was often found in precarious positions, such as lying halfway down the bed or on the floor, indicating inadequate supervision and fall prevention measures. The facility's incident/accident reports for R85's falls were incomplete, lacking crucial information such as staff interviews, root cause analyses, and notifications to the physician or responsible party. In several instances, the reports failed to document any new interventions or updates to the resident's care plan following the falls. Interviews with the Director of Nursing (DON) highlighted a lack of awareness and oversight regarding the incomplete documentation and insufficient fall investigations. The DON acknowledged the issues but was unable to provide additional documentation or explanations for the deficiencies. The facility's policy on fall management, which requires thorough evaluation and documentation of falls, was not adhered to, resulting in repeated failures to address the resident's fall risks effectively.
Inadequate Staffing and Supervision in LTC Facility
Penalty
Summary
The facility failed to consistently provide sufficient nursing staff to meet the needs of its residents, leading to complaints of delayed care and lack of supervision. The staffing plan outlined in the facility's policy required 16 licensed nurses and 24 nurse aides across various shifts, but the actual staffing levels often fell short of these requirements. This discrepancy resulted in inadequate supervision and care for residents, particularly those with wandering behaviors, such as a resident identified as R86. R86, who has diagnoses including dysthymic disorder, Down syndrome, and unspecified intellectual disabilities, was observed wandering unsupervised in the facility. On multiple occasions, R86 entered other residents' rooms and was found in areas without staff presence, displaying signs of distress and engaging in potentially harmful behaviors. Despite these observations, the Director of Nursing (DON) did not believe increased supervision was necessary, citing that the resident's outbursts would not be mitigated by one-on-one supervision. The facility's failure to provide adequate staffing and supervision was further compounded by the lack of documentation for certain dates and the absence of the Administrator during the survey. The DON, acting as the point of contact, did not express concern over staffing levels, even though the facility's staffing did not align with the documented plan. This lack of supervision and staffing inadequacy posed a risk to all residents, particularly those like R86, who require more attentive care due to their behavioral and cognitive challenges.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as evidenced by multiple observations of pills and capsules found on the floor in common areas. On one occasion, a pink oblong pill identified as omeprazole was found in the central shower room, which a Licensed Practical Nurse (LPN) retrieved with bare hands, indicating it may have fallen from a medication cart. Additional pills and capsules were found in the hallway and dining area, with staff members picking them up without proper precautions, suggesting a lack of adherence to medication handling protocols. A resident, identified as R70, was observed with a bottle of eye drops on their overbed tray table, despite a previous assessment indicating they were not capable of self-administering medication due to severe cognitive impairment. The Director of Nursing (DON) confirmed that the resident should not have had the eye drops at bedside and removed them, acknowledging that the family had brought in the medication without proper authorization or assessment. Further deficiencies were noted at the 2nd floor nursing station, where 25 boxes of COVID-19 Rapid Tests were stored unsecured on an open shelf, and both the medication and treatment carts were found unlocked with no staff present. The Infection Control Nurse and the assigned nurse were unaware of the unlocked carts, and the DON confirmed that this was against facility policy, which mandates that all medications and biologicals be securely stored in locked compartments.
Infection Control Deficiencies in Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to implement effective infection control practices, specifically in the areas of hand hygiene during medication administration and the application of Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Observations revealed that a resident with a urinary catheter did not have appropriate signage or Personal Protective Equipment (PPE) available, indicating a lack of EBP implementation. A Certified Nurse Aide (CNA) assigned to the resident was unaware of any infection control precautions, and it was only after the surveyor's intervention that signage and a PPE cart were placed outside the resident's room. The resident's clinical record indicated the need for EBP due to the presence of an indwelling urinary catheter, yet this was not initially adhered to. Additionally, during a medication pass, multiple nurses failed to perform hand hygiene before and after administering medications to residents. This was observed with several nurses who completed medication administration without washing their hands, despite the Director of Nursing (DON) confirming that hand hygiene is expected to be performed before and after each resident interaction. These lapses in infection control practices present a potential risk for cross-contamination and the spread of infection within the facility.
Incomplete Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the specific nutritional needs of a resident, identified as R297, who was admitted with multiple complex medical conditions including severe protein-calorie malnutrition and morbid obesity. The care plan initiated by the Director of Nursing was incomplete, lacking specific interventions tailored to the resident's nutritional needs and risks. Despite the presence of a mechanically altered diet, there was no documentation of a thorough nutritional assessment or specific interventions in the resident's care plan. Conflicting documentation was noted in the physician and nurse practitioner progress notes, which referenced a nutritional care plan and monitoring that were not available in the clinical record. The Registered Dietitian (RD) confirmed that they did not perform the evaluation due to being out sick and was unsure who was responsible for nutritional monitoring in their absence. The facility's policy on nutritional services documentation was not adhered to, as the nutritional evaluation was not used to develop an individualized care plan for the resident, leading to the deficiency.
Deficiency in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure nursing services met professional standards for medication administration and documentation for a resident who was reviewed for self-administration. The resident, who was cognitively intact with a BIMS score of 14/15, had a medical history of hepatitis, hypertension, diabetes, and psychiatric conditions including major depressive disorder, bipolar disorder, and anxiety. During observations and interviews, the resident expressed concerns about the application of a medicated lotion left at their bedside. The resident was unaware of the lotion's purpose and noted that it was left uncovered, raising concerns about sanitation. The resident reported that nurses did not confirm whether the lotion was applied and simply left it at the bedside. A review of the Medical Administration Record (MAR) indicated that the resident was prescribed Benzoyl Peroxide External Gel 5% to be applied once daily for a topical infection/acne. However, the Licensed Practical Nurse (LPN) responsible for administering the medication acknowledged leaving it at the bedside without applying it or confirming its application with the resident. The LPN did not respond to questions about whether the resident had orders to self-administer the medication and walked away from the surveyor. The Nursing Home Administrator was informed of the interaction but provided no further explanation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three residents, resulting in them being left wet for extended periods. One resident was observed asking for assistance to be changed, but the staff member left without helping. A nurse later turned off the call light without providing assistance, and the resident was only helped after a significant delay. Another resident's call light was on for over 30 minutes before they were assisted, and they expressed discomfort from waiting to be changed. The Director of Nursing acknowledged that call lights should be answered within 30 minutes but did not provide further information by the survey's exit. Another resident reported being left in wet sheets overnight, despite informing the midnight aide, who did not return to assist them. The resident expressed feeling upset and uncomfortable due to the lack of care. A CNA confirmed that this resident was often found in such a condition at the start of their shift. The resident's care plan indicated they required assistance with activities of daily living due to weakness and needed to be checked every two hours for incontinence. The resident was cognitively intact, as indicated by their MDS assessment, which showed they required moderate assistance with toileting and were frequently incontinent.
Failure to Notify Physician of Resident's Skin Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident who was experiencing skin issues. The resident, who was admitted with a diagnosis of nontraumatic subdural hemorrhage, major depressive disorder, and muscle weakness, reported itching and burning on their skin, suspecting an abscess. Despite informing the nursing staff, no action was taken to address the issue, and the resident's family member was also aware of the resident's discomfort and desire to see a doctor. The resident's medical record showed no indication of the skin issue in the weekly skin assessments. The deficiency was identified during an interview with the resident and their family member, where the resident expressed dissatisfaction with the delay in receiving care for their skin condition. The Director of Nursing was unaware of the issue until informed by the surveyor, and only then was a wound care consult and hydrocortisone cream order placed. This indicates a lapse in communication and timely response to the resident's change in condition, as the facility's staff did not document or address the resident's complaints until after the surveyor's intervention.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services for a resident, identified as R25, who was observed with limited range of motion in their legs. R25 was previously receiving restorative therapy before a hospital stay but did not resume these services upon returning to the facility. The resident expressed a desire to continue therapy due to increased tightness in their legs, but no restorative therapy was provided during the 30-day look-back period. The Restorative Aide confirmed that R25 was not on their caseload post-hospitalization, and the Rehabilitation Director was unaware of the gap in services. The Director of Nursing (DON) acknowledged that the facility did not have a fully functioning restorative program and lacked a restorative nurse to oversee the program. The DON admitted that R25 should have been screened for restorative services after their hospital stay, especially given the report of contractures beginning. Despite the resident's needs and expressed wishes, there was no documentation of a contracture diagnosis in R25's records, and the care plan did not reflect the need for restorative therapy. Observations revealed that R25's heels were pressing on the mattress, and their legs showed signs of stiffness and limited range of motion. The DON attempted to perform range of motion exercises with R25, noting potential contractures. The facility's policy on restorative nursing emphasizes the importance of maintaining residents' physical well-being, but the lack of a structured program and oversight led to a deficiency in providing necessary restorative care for R25.
Failure to Conduct Comprehensive Nutritional Assessment
Penalty
Summary
The facility failed to conduct a comprehensive nutritional assessment and ongoing evaluation for a resident, R297, who was admitted with significant nutritional needs following a gastric sleeve revision surgery with complications. The resident's clinical record indicated multiple serious diagnoses, including severe protein-calorie malnutrition and morbid obesity. Despite these conditions, the facility did not complete a comprehensive nutritional assessment or provide specific interventions tailored to the resident's needs. The care plan initiated by the Director of Nursing was incomplete, and there was no evidence of a comprehensive assessment by the Registered Dietician (RD). The resident's physician orders included a mechanically altered diet and nutritional supplements, but there was no documentation of a comprehensive nutritional assessment or progress notes by the RD in the clinical record. The RD confirmed that they did not perform the evaluation and were unaware of a STAT order for an RD evaluation. The RD was out sick on a critical date and was unsure who was responsible for nutritional monitoring in their absence. The RD also acknowledged that the assessment was initiated but not completed, and there was no documentation of specific nutritional needs, including protein or TPN. The facility's policy required a comprehensive nutritional evaluation upon admission, which was not adhered to in this case. The RD reported having discussions with physicians via text but did not complete an actual nutritional assessment. The lack of a comprehensive nutritional assessment and care planning for R297, despite the resident's significant nutritional needs and physician orders, led to the deficiency identified in the report.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure appropriate use of psychotropic medication for a resident, identified as R85, who was admitted with multiple diagnoses including hemiplegia, generalized anxiety disorder, dysthymic disorder, and vascular dementia. Despite having severe cognitive impairment and no documented behaviors or psychosis, R85 was prescribed Alprazolam as needed for agitation. The medication was administered multiple times in December and January without documentation of non-pharmacological interventions being attempted first, as required by the facility's policy. Additionally, there were no corresponding entries in the interdisciplinary progress notes at the time of the PRN administrations, and the documented behaviors did not align with the times the medication was given. During an interview, the Director of Nursing acknowledged the lack of documentation and confirmed that the nurses should have recorded the interventions on the Medication Administration Records or progress notes. The DON also questioned the appropriateness of the medication being ordered for agitation and indicated a need to follow up with the contracted psych provider who issued the orders. The facility's policy on psychoactive medication management emphasizes non-pharmacologic interventions as the first choice for managing behavioral symptoms and requires a clinically supported diagnosis for pharmacological interventions.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to obtain and coordinate timely radiology services for a resident who experienced a fall. Following the fall, a physician ordered an X-ray of the resident's left shoulder on 1/13/25. However, as of 1/15/25, the X-ray had not been completed, and there was no radiology report available in the electronic medical record. The radiology log at the nursing station showed that the request for the X-ray had not been fulfilled, despite the physician's order. The Director of Nursing (DON) indicated that X-rays should typically be completed within 24 hours unless ordered STAT, but there was no facility policy addressing the timeframe for obtaining X-rays. The resident involved had a history of idiopathic normal pressure hydrocephalus, hemiplegia and hemiparesis following cerebral infarction, neurologic neglect syndrome, and a nonruptured cerebral aneurysm. At the time of the deficiency, the resident reported significant pain in the left shoulder, rating it as a seven on a scale of zero to ten. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and occasional pain affecting daily activities. Despite the physician's order and the resident's reported pain, the X-ray was not completed until after the survey identified the issue.
Failure to Administer Vaccines After Consent
Penalty
Summary
The facility failed to ensure the administration of pneumococcal and influenza vaccines for a resident, identified as R3, who was admitted with a medical history of influenza, pneumonia, heart failure, osteoarthritis, and gastrointestinal hemorrhage. R3, whose primary language is Arabic/Chaldean, consented to receive the vaccines through their daughter, who acted as a translator. Despite this consent, the facility's Electronic Medical Record (EMR) showed no documentation of the vaccines being administered. The Infection Control Preventionist (ICP) confirmed that the vaccines were not given and that the physician had discontinued the orders without documented rationale. Furthermore, there was no follow-up communication with R3 or their daughter regarding the discontinuation of the vaccines, leading to the daughter mistakenly believing that R3 had received them.
Failure to Timely Treat Diabetic Ulcer Leads to Amputation
Penalty
Summary
The facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer for a resident, resulting in a hospital transfer and subsequent amputation of the resident's left great toe. The resident, who had a history of diabetes, peripheral vascular disease, and previous amputations, was admitted to the facility with a diabetic ulcer. Despite the presence of a wound on the left great toe, there was a significant delay in treatment orders, with no treatment initiated until several weeks after the ulcer was first documented. The facility's records revealed inconsistencies in the documentation of the wound's condition and treatment. The wound was first noted by a dietary note, but there were no prior progress notes mentioning the wound. The wound care assessments and consultations by the facility's contracted wound PA showed discrepancies in measurements and descriptions of the wound, with no treatment orders in place for a significant period. The facility's Wound Care Coordinator and PA failed to provide consistent and timely documentation and treatment for the resident's wound, leading to its deterioration. Interviews with facility staff, including the Wound Care Coordinator and the DON, highlighted a lack of proper wound management and documentation. The DON acknowledged issues with the previous Wound Care Coordinator and discrepancies in the wound consults. The facility's policy on skin management was not adhered to, as ongoing monitoring and evaluation were not provided to ensure optimal outcomes for the resident. This lack of adherence to policy and failure to provide timely and appropriate care resulted in the resident's condition worsening, necessitating a hospital transfer and amputation.
Unresolved Odor Issue in Hallway Near Dining Room
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in the hallway near the main dining room, as evidenced by a strong, putrid, sour odor that was present. This odor was first observed in the hallway extending from the main dining room to the lobby. The Registered Dietician (RD) 'E' suggested that the odor might be due to a problem with the dish machine, which was located in the hallway where the odor was detected. The Infection Control Nurse/Staff Development Nurse, Staff 'D', also acknowledged the presence of the pungent odor in the same area. Further investigation revealed that the Housekeeping Supervisor (HK) 'F' attributed the odor to an issue with the dish machine that required repairs. An observation of the dish room showed a wet floor, but the odor was not present inside the dish room itself, only in the hallway outside. The Administrator reported being unable to detect the odor, while the Maintenance Assistant 'H' confirmed awareness of the odor, noting that the source had not been identified despite its presence for a couple of weeks.
Neglect in Medication Administration by RN
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by the actions of a registered nurse (RN B) who did not administer medications to three residents as documented. A complaint was filed alleging that RN B did not administer medications to a resident (R701) on a specific date, despite documentation indicating otherwise. Surveillance footage confirmed that RN B did not enter the resident's room during the time the medications were supposedly given. The resident's family member, who was present during the alleged time of administration, corroborated that the medications were not administered. Further investigation revealed that RN B also failed to administer medications to two other residents (R704 and R705) on the same unit. Both residents reported inconsistencies in receiving their medications, with one resident noting that they sometimes did not receive their medications at all. The facility's surveillance footage showed that RN B did not enter the rooms of these residents during the medication administration period, and the medication administration records (MAR) were inaccurately documented as if the medications had been given. Interviews with the Director of Nursing (DON) and other staff members revealed discrepancies in RN B's work schedule and time card punches, suggesting that RN B left the facility earlier than scheduled without properly administering medications. The DON and the facility's administrator were unable to provide explanations for the discrepancies observed in the surveillance footage and the MAR documentation. This failure to administer medications as prescribed and the inaccurate documentation constituted neglect of the residents' care needs.
Failure to Verify Active Nursing License
Penalty
Summary
The facility failed to ensure that a nurse, referred to as Nurse A, had an active license to practice as an LPN. A complaint was filed with the State Agency alleging that Nurse A was working with a suspended license. Upon investigation, it was confirmed that Nurse A's license had been suspended in February 2024. Despite this suspension, Nurse A continued to be employed and worked shifts at the facility, including a night shift on June 4, 2024. The facility's records showed that Nurse A had been employed since September 2023. Interviews with facility staff revealed gaps in the process of verifying nursing licenses. The Human Resources staff member responsible for checking licenses had only been employed for three weeks and had not yet reviewed all nursing staff licenses, including Nurse A's. The Director of Nursing and the Administrator were unaware of the suspension until it was confirmed during the investigation. The facility's policy required that all staff in licensed positions have a current license, but this policy was not effectively implemented in Nurse A's case.
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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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