Oakridge Manor Nursing And Rehabilitation Center L
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferndale, Michigan.
- Location
- 3161 Hilton Rd, Ferndale, Michigan 48220
- CMS Provider Number
- 235322
- Inspections on file
- 24
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakridge Manor Nursing And Rehabilitation Center L during CMS and state inspections, most recent first.
A resident with multiple medical conditions was not included in discussions about dialysis, feeding tube removal, or advance directives, despite being able to express his wishes and understand the risks. Staff and the legal guardian made decisions without involving the resident, including attempting to petition for involuntary psychiatric evaluation and initiating hospice consults, contrary to facility policy requiring resident participation in care decisions.
Surveyors found that an LPN had stored four one-dollar bills and an open bottle of hand sanitizer in a medication cart, with the sanitizer placed in the same compartment as a nebulizer treatment. The DON confirmed that neither money nor cleaning supplies should be stored with medications, and facility policy requires separate storage for external and internal drugs.
The facility did not ensure accurate MDS assessments for several residents, including errors in discharge coding, medication reduction documentation, weight change reporting, and pressure ulcer staging. Staff relied on incomplete or incorrect information from records and did not verify clinical details, leading to inaccurate assessments.
A resident with cognitive impairment and mobility needs was repeatedly observed without access to their call light, which was found out of reach on several occasions. Despite care plan interventions and staff acknowledgment of the requirement, the call light was not consistently placed within the resident's reach, preventing the resident from alerting staff for assistance.
A resident with severe cognitive impairment was observed with a bandage showing drainage on the forearm, but there was no physician order for wound care, and staff were unaware of who applied the dressing. The facility failed to assess, monitor, and treat the skin tear according to policy, resulting in the wound remaining unaddressed for at least a day.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents, including a fall resulting in a head laceration and hospital transfer. The facility did not complete required incident or investigation reports, failed to conduct a root cause analysis, and did not consistently implement recommended fall prevention interventions such as ensuring proper footwear, as observed by staff and documented in the care plan. Staff interviews revealed a lack of awareness and follow-up regarding the incident, in violation of facility policy.
A resident with multiple medical conditions was admitted with a Foley catheter, but the facility failed to assess the need for continued catheter use, did not obtain physician orders for catheter care, and did not arrange a urology follow-up as recommended. Staff were unaware of the lack of orders, and documentation supporting the catheter's use was incomplete, contrary to facility policy.
A resident with multiple medical conditions experienced a significant, unaddressed weight loss, with staff failing to confirm, report, or intervene despite clear documentation and policy requirements. Nutritional assessments and care plans did not reflect or respond to the weight change, and staff attributed discrepancies to weighing errors without formal evaluation.
A resident with multiple diagnoses and severe cognitive impairment did not have pharmacy-recommended labs ordered after a medication regimen review, despite the physician agreeing to the recommendations. While the labs were eventually drawn after a subsequent recommendation, there was no documentation or tracking to confirm that the initial recommendation was acted upon, and staff interviews revealed inconsistent practices for recording lab orders.
Three residents with complex medical histories did not receive timely pneumococcal vaccinations due to the facility's failure to accurately track immunization status and follow current CDC guidelines. The LPN responsible for infection control relied on incomplete admission paperwork for consent and did not directly approach residents, while also using outdated vaccination protocols, resulting in missed or delayed vaccinations.
Three residents with a history of or risk for pressure ulcers did not receive consistent skin monitoring or appropriate preventative interventions as ordered. One resident's heel boots were not applied and the air mattress was set incorrectly, while another was not provided with a pressure-reducing mattress despite a care plan intervention. Weekly skin assessments were not completed as required for all three residents, and staff interviews revealed confusion and lack of follow-up on identified skin concerns.
Surveyors found that several rooms did not meet the required minimum square footage per resident, with multiple shared rooms and single rooms falling below the standards. Residents interviewed reported no dissatisfaction or problems related to their room sizes, and no health or safety concerns were identified.
A facility failed to protect a resident from physical abuse by another resident, resulting in a split, bleeding, and swollen lip. The incident occurred when one resident refused to lower their TV volume, leading to the other resident becoming upset and physically assaulting them. Both residents were cognitively intact, and there had been no prior conflicts between them. The facility's policy on abuse prevention was not effectively implemented, and local authorities were contacted, resulting in a police report.
A resident admitted with type 2 diabetes mellitus and continence issues did not receive a comprehensive admission assessment within the required timeframe. The MDS assessment was incomplete, and the DON was unaware of this oversight. The facility's policy requires completion within 14 days.
A resident admitted with type 2 diabetes mellitus was not assessed for incontinence, despite having a saturated brief and reporting urinary incontinence upon admission. The facility's policy required a comprehensive assessment for incontinence, but the resident's Minimum Data Set (MDS) assessments were incomplete, and no admission nursing assessment was conducted. The Director of Nursing was unaware of the oversight, leading to a deficiency in care.
A resident with atrial fibrillation, diabetes, and depression developed contractures in three fingers due to the facility's failure to identify and implement interventions for changes in range of motion (ROM). The resident's care plan lacked ROM goals and interventions despite complaints about limited ROM. The Occupational Therapist (OT) was unaware of the limitations until an observation, where attempts to straighten the fingers were unsuccessful. The facility's policy on preventing ROM decline was not effectively implemented, and a Certified Nursing Assistant (CNA) had noticed decreased ROM weeks prior without appropriate actions being taken.
The facility failed to ensure proper medication administration and documentation for four residents. An LPN left medications unattended, did not remove an unauthorized inhaler, and administered the wrong form of Aspirin. Another resident reported delays in receiving Tylenol for phantom pain, and an RN admitted to giving Tylenol without a physician order.
The facility failed to ensure an environment free from hazards by not securing portable oxygen tanks properly. Surveyors observed an oxygen tank in a resident's room and another behind the nursing station, both unsecured. The Nurse Manager confirmed that all portable oxygen tanks should be stored with appropriate securing devices, as per the facility's policy on oxygen safety.
The facility failed to remove expired medical supplies, maintain a daily log of refrigerator temperatures, and provide refrigerated medication at the recommended temperature. Observations revealed an unlocked refrigerator with improper temperatures and expired supplies, contrary to the facility's Medication Storage Policy.
The facility failed to maintain the dignity and proper care of three residents. One resident was repeatedly seen without a bra, another was improperly transported in a geriatric chair, and a third was left in soiled clothing for an extended period. These incidents indicate a lack of adherence to care plans and proper procedures.
The facility failed to properly evaluate and clarify the advance directive code status for a resident receiving hospice services. Despite an advance directive indicating full resuscitation, the EMR incorrectly identified the resident as DNR. Further investigation revealed that the DNR paperwork was not legally binding, and the resident's code status was subsequently changed to Full Code.
The facility failed to notify a resident's responsible party before transferring the resident to the hospital due to a dislodged PEG tube. The resident was severely cognitively impaired and bedbound with multiple diagnoses. The NHA and DON confirmed that no notice of transfer was documented or provided, as required by the facility's policy.
The facility failed to document that the Physician/Prescriber acknowledged identified irregularities from the medication regimen review for two residents, despite recommendations for gradual dose reductions of Sertraline and Alprazolam.
The facility failed to obtain physician-ordered lab tests for a resident with multiple diagnoses, resulting in potential unreported abnormal lab results. The resident's medical record lacked results for several ordered tests, and the nurse manager confirmed they were not performed. Additionally, abnormal UA results were not documented as reported to the physician.
The facility failed to implement enhanced barrier precautions (EBP) and educate staff on proper procedures for two residents. One resident with an indwelling urinary catheter had no EBP signage or PPE, and staff did not use PPE while providing care. Another resident on EBP due to cystitis was cared for by a CNA who did not use gloves or a gown, despite PPE being available.
The facility failed to provide the required 80 square feet per resident for 16 of 20 multiple resident rooms and 100 square feet for 4 of 4 single resident rooms. Despite the inadequate space, interviews with residents revealed no complaints or dissatisfaction with their living conditions.
Failure to Honor Resident's Right to Participate in Treatment Decisions
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in decisions regarding their treatment, specifically related to dialysis, feeding tube, and advance directives. The resident, who had multiple complex medical diagnoses including end stage renal disease, heart disease, and a history of traumatic brain injury, expressed frustration about not being included in discussions about his care and not being able to communicate with his legal guardian. Despite being cognitively able to express his wishes and understanding the risks of refusing dialysis, the resident reported that neither the facility staff nor his legal guardian engaged him in meaningful conversations about his treatment preferences or goals of care. Documentation and interviews revealed that the resident refused dialysis on several occasions, preferring to attend only twice a week instead of the physician-recommended three times. Staff responses included contacting the resident's daughter to convince him to comply, notifying the provider, and ultimately involving the legal guardian, who had not visited or communicated directly with the resident since admission. There was no evidence that the facility or the guardian discussed the reasons for the resident's refusals or his wishes regarding his care. Instead, the facility attempted to petition for involuntary psychiatric evaluation, citing non-compliance with dialysis, despite EMS and staff acknowledging the resident was of sound mind and not in distress. Further, the resident expressed a desire to have his feeding tube removed and to have input on his code status and hospice care, but reported that no one had discussed these options with him. Social services documentation showed that hospice was discussed with the guardian but not with the resident, and the resident was not included in care conferences or decisions about his code status. The facility's own policy required that residents or their representatives be informed and included in decisions about treatment and advance directives, but this was not followed in the resident's case.
Improper Storage of Medications and Biologicals in Medication Cart
Penalty
Summary
Surveyors observed that medications and biologicals were not stored in a safe and sanitary manner in one medication cart. During an inspection of the 2nd floor medication cart with an LPN, four one-dollar bills were found folded in the top left drawer, and the LPN was unable to identify the owner of the money. In the third left drawer, an open bottle of hand sanitizer with a pump was stored in the same compartment as a nebulizer treatment for inhalation. The LPN acknowledged that the hand sanitizer should not have been stored with medications and removed it immediately. The Director of Nursing confirmed that money should not be kept in medication carts and that cleaning supplies should not be stored with medications. Facility policy requires that disinfectants and drugs for external use be stored separately from internal and injectable medications.
Failure to Ensure Accurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four out of thirteen residents reviewed. In one case, a resident was incorrectly coded as being discharged to a short-term general hospital, when documentation showed the resident was actually transferred to another long-term care facility. The MDS Coordinator admitted this was an accidental error during the assessment process. Another resident's MDS assessment inaccurately indicated that a gradual dose reduction (GDR) of an antipsychotic medication had occurred, including an incorrect date. Review of psychiatric evaluations and clinical records showed that no GDR was indicated or performed, and the date referenced did not correspond to any actual evaluation. The MDS Coordinator misunderstood the process, believing a GDR was performed with every psychiatric evaluation, and did not verify the information. A third resident's weight records showed significant fluctuations, but the MDS assessment did not accurately reflect these changes, nor was there documentation verifying the accuracy of the weights or actions taken to confirm them. The MDS Coordinator stated she only signed off on the assessments and did not verify the calculations, relying on dietary staff for accuracy. In another case, a resident was incorrectly coded as having a stage 3 pressure ulcer on admission, based on transfer documentation from another facility, without physical verification or accurate assessment by qualified staff. Interviews with nursing and administrative staff confirmed that the resident did not have a stage 3 pressure ulcer after admission, and the MDS Coordinator relied solely on previous records rather than current clinical findings.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident was repeatedly observed without access to their call light while in bed. On multiple occasions, the call light was found behind the head of the bed on the floor or clipped to a bed sheet out of the resident's reach. The resident, who had moderately impaired cognition and required partial to moderate assistance with bed mobility and activities of daily living, was unable to reach the call light when asked. The resident reported relying on the call light to alert staff for assistance, but was unable to access it during the observations. Interviews with nursing staff, including an LPN and the Director of Nursing, confirmed that all staff were required to ensure call lights were within reach of residents. The resident's care plan specifically included an intervention to keep the call light in reach at all times due to a risk for falls related to poor safety awareness and the need for assistance with mobility. Despite this, staff failed to ensure the call light was accessible, as evidenced by repeated observations and staff acknowledgment of the requirement.
Failure to Assess and Treat Skin Tear per Physician Orders
Penalty
Summary
The facility failed to properly assess, monitor, and treat a skin tear for one resident with severely impaired cognition and multiple diagnoses, including dementia and altered mental status. The resident was observed with an adhesive foam bandage on the right forearm that showed visible drainage, but there was no documentation of a physician's order for the dressing. The clinical record indicated that the skin tear was initially left open to air, and there was no clear documentation or communication regarding the application of the dressing. Nursing staff, including the assigned LPN and the unit manager, were unaware of any orders for wound care or who had applied the dressing. The dressing remained unchanged with visible drainage for at least a day, and the resident was unable to explain the presence of the bandage due to cognitive impairment. Facility policy required that wound treatments be provided according to physician orders, and in the absence of such orders, the licensed nurse was to notify the physician to obtain appropriate treatment directives. Despite this, no physician order was obtained for the dressing or wound care, and there was a lack of communication among staff regarding the resident's skin tear and its management. The failure to follow policy and ensure proper assessment and treatment led to the deficiency identified during the survey.
Failure to Investigate and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to thoroughly investigate and conduct a root cause analysis of a fall incident involving a resident with severe cognitive impairment, dementia, and a history of falls. The resident, who was admitted with multiple diagnoses including unsteady gait and schizoaffective disorder, experienced several falls and an accident resulting in injury. Despite these incidents, the facility did not consistently implement or document fall prevention interventions as recommended in the resident's care plan. Observations showed the resident frequently wore non-skid socks instead of shoes, even after an intervention specifying the need for proper footwear was added to the care plan following a previous injury. A review of the resident's medical record and incident reports revealed multiple falls and accidents, including one where the resident fell out of bed and sustained a laceration to the head, requiring hospital transfer. However, the facility did not provide an incident or investigation report for this event, and there was no evidence of immediate interventions or a thorough investigation following the incident. Interviews with staff, including the LPN, unit manager, and DON, indicated a lack of awareness and follow-up regarding the fall, with the DON confirming they were not notified of the event and no investigation report was completed. The facility's own policy requires staff to report, investigate, and review all incidents and accidents, including conducting root cause analyses and implementing immediate interventions. Despite this, the required documentation and follow-up were not completed for the resident's fall on 3/9/25, and the intervention for proper footwear was not consistently implemented, as evidenced by multiple observations of the resident without shoes. This failure to follow policy and ensure consistent implementation of fall prevention measures contributed to the deficiency.
Failure to Assess and Document Indwelling Catheter Use and Care
Penalty
Summary
A deficiency occurred when a resident admitted with an indwelling urinary catheter was not properly assessed for catheter removal, did not receive a follow-up with a urologist as ordered, and lacked physician orders for catheter care. The resident, who had a history of brain cancer, dementia, recent hospitalization, and multiple other medical conditions, was observed on several occasions with a Foley catheter in place. Despite the presence of the catheter, there were no corresponding physician orders for its use or care documented in the resident's medical record since admission. Review of the resident's hospital discharge summary did not reveal a diagnosis of urinary retention or any urologist consultation, even though the facility's records listed urinary retention as a diagnosis. The Minimum Data Set (MDS) assessment and care area documentation did not provide a clinical rationale for the ongoing use of the indwelling catheter, and the section supporting the use of the Foley catheter was left blank. Additionally, a physician's note recommended a urology follow-up, but there was no evidence that this follow-up occurred. Interviews with facility staff, including an LPN and the DON, confirmed that there were no physician orders for the catheter and that staff were unaware of this omission. The facility's own policy requires that indwelling catheters be used only when clinically necessary, with appropriate documentation, physician orders, and ongoing assessment, none of which were present in this case.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
A significant deficiency occurred when the facility failed to identify and address a substantial weight loss in a timely manner for a resident with multiple medical conditions, including normal pressure hydrocephalus, diabetes, and frontotemporal neurocognitive disorder. The resident was observed refusing or not consuming meals, expressing dislike for the food, and not requesting alternatives. Despite these observations and a documented history of poor appetite and gastrointestinal issues, there was no evidence that the facility took appropriate action to assess or intervene regarding the resident's nutritional status during the period of weight loss. The clinical record showed that the resident experienced an 11.31% loss of body weight within 30 days, dropping from 194.6 pounds to 172.6 pounds. However, there was no documentation of a re-weigh to confirm the accuracy of this loss, nor was there evidence that the weight loss was reported to or evaluated by the dietary department or physician. Nutritional assessments completed after the weight loss failed to acknowledge or address the significant change, and progress notes from both the Certified Dietary Technician and Registered Dietitian did not reflect any investigation or intervention related to the weight loss. Interviews with facility staff revealed that discrepancies in weight documentation were attributed to errors by the staff responsible for weighing residents, but no formal evaluation or documentation was made to confirm whether the weight loss was genuine or erroneous. Additionally, the resident's care plan, which identified a risk for nutrition-related declines, did not include any new interventions following the documented weight loss. The facility's policy required monitoring and reporting of significant weight changes, as well as weekly monitoring for residents with weight loss, but these procedures were not followed. The lack of timely identification, assessment, and intervention for the resident's significant weight loss constitutes a failure to provide adequate nutrition and hydration to maintain the resident's health.
Failure to Complete Pharmacy-Recommended Lab Orders After Medication Regimen Review
Penalty
Summary
The facility failed to ensure that irregularities identified by the consultant pharmacist during the monthly medication regimen review were completed for one resident. The resident, who had diagnoses including heart failure, dementia, and anxiety disorder, was noted to have severely impaired cognition and required staff assistance for activities of daily living. The consultant pharmacist made recommendations on two occasions for the physician to order specific laboratory tests, including a lipid panel and TSH levels. The physician agreed to these recommendations and signed off on them. However, documentation revealed that while the labs were eventually drawn following the second recommendation, there was no evidence that the labs were ordered or completed after the initial recommendation. Interviews with an LPN and the DON indicated that there was no consistent documentation or tracking system in place to confirm when labs were ordered, and the facility was unable to verify if the initial pharmacy recommendation had been acted upon. The facility's policy required staff to act upon all recommendations from the medication regimen review, but this was not followed in this instance.
Failure to Accurately Track and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure accurate tracking and administration of pneumococcal vaccinations for three of five residents reviewed. For one resident with a history of right femur fracture, COPD, and chronic respiratory failure, there was no record of any pneumococcal vaccination, and the Michigan Care Improvement Registry (MCIR) indicated the resident was overdue for the vaccine. Another resident with heart failure, dementia, and anxiety disorder had received a pneumococcal vaccine in the past, but was overdue for an additional dose according to MCIR and CDC guidelines, with no record of the vaccine being administered by the facility. A third resident with diabetes, acute respiratory failure, and liver transplant status had received previous pneumococcal vaccines, but was also overdue for the recommended dose, with discrepancies noted between the facility's records and the MCIR. During an interview, the LPN responsible for infection control stated that she relied on consent forms included in admission paperwork before offering vaccinations and did not approach residents directly to obtain consent. The LPN also demonstrated a lack of current knowledge regarding CDC guidelines for pneumococcal vaccination, relying instead on outdated practices and assumptions about vaccine requirements based on age and timing of previous doses. These actions and inactions resulted in residents not receiving timely and appropriate pneumococcal vaccinations as required by facility policy and CDC recommendations.
Failure to Consistently Monitor and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to consistently monitor and assess the skin of residents at risk for or with existing pressure ulcers, as required by physician orders and facility policy. For one resident, observations revealed that heel boots intended to prevent pressure ulcers were not applied, and the resident's heels were in direct contact with the mattress. The specialty air mattress was set incorrectly for the resident's weight, and there were gaps in the completion of weekly skin assessments as ordered by the physician. The care plan lacked specific instructions regarding the mattress settings, and the intervention to float the heels was not consistently implemented. Another resident, admitted with a stage 3 pressure ulcer, was observed on a regular mattress rather than a pressure-reducing device as indicated in the care plan. The resident's medical record showed inconsistent completion of weekly skin assessments, with a significant gap of over two weeks without documentation. The care plan included an intervention for a low air loss mattress, but this was not in place, and staff were unclear about the rationale for this intervention. A third resident, with a history of pressure ulcers and multiple risk factors, also did not have weekly skin assessments completed as ordered. After readmission, there was a month-long gap without documented skin assessments, and multiple shower sheets indicated areas of redness or open skin that were not followed up by a nurse. Interviews with staff revealed confusion about the process for completing and documenting skin assessments, and discrepancies were noted between CNA shower sheets and nursing documentation, with no further assessment or follow-up on identified skin concerns.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in several rooms, as observed during a survey. Specifically, 7 out of 20 multiple resident rooms did not meet the 80 square feet per resident requirement, and 3 out of 4 single resident rooms did not meet the 100 square feet per resident requirement. Room measurements were documented, showing that some rooms designated for three residents were under the required space, and several single rooms were also below the standard. Despite these deficiencies, interviews with residents indicated that they had no complaints or issues with their room sizes, and there was no evidence that the health and safety of residents were affected by the room dimensions.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. The incident involved two residents, one of whom was cognitively intact with a BIMS score of 15/15, and the other with a BIMS score of 13/15, indicating cognitive intactness as well. The incident occurred when one resident refused to lower the volume of their television, leading to the other resident becoming upset and physically assaulting them by punching them in the face. This resulted in the victim sustaining a split, bleeding, and swollen lip. The incident was reported by a CNA who observed the injury during morning care. The facility's policy on abuse, neglect, and exploitation, dated November 2022, states that efforts will be made to ensure all residents are protected from physical and psychosocial harm. Despite this policy, the incident occurred, and the local authorities were contacted, resulting in a police report being filed. Interviews with the involved residents and staff confirmed the details of the incident, and it was noted that there had been no prior conflicts between the two residents or with others, making the event unexpected.
Incomplete Admission Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive admission assessment for a resident, identified as R701, within the required timeframe. R701 was admitted with a diagnosis of type 2 diabetes mellitus and had issues with bowel and bladder continence. Despite being admitted, the Minimum Data Set (MDS) assessment for R701 was incomplete, with a due date set for 14 days post-admission. Key sections, including the assessment for bowel and bladder continence, were not completed. During an interview, the Director of Nursing (DON) was unaware of the incomplete assessment, and no additional information was provided by the MDS coordinator before the survey concluded. The facility's policy mandates that a comprehensive admission assessment be completed within 14 days of admission.
Failure to Assess Incontinence in Resident
Penalty
Summary
The facility failed to complete an assessment for incontinence for a resident, identified as R701, who was admitted with a diagnosis including type 2 diabetes mellitus. Upon admission, it was documented that R701 had a saturated brief and reported being incontinent of urine. Despite this, there was no admission nursing assessment or assessment for incontinence completed for R701. The Minimum Data Set (MDS) assessments were in progress, but R701 had not been assessed for urinary continence, even though he had intact cognition. Progress notes indicated that R701 expressed a preference for using briefs and being changed in bed rather than being accompanied to the bathroom every few hours. Interviews with the Director of Nursing (DON) and a Social Worker revealed that residents were supposed to be assessed for urinary continence using an assessment tool and through the MDS assessment upon admission, quarterly, and as needed. However, the DON was unaware that R701 had not been assessed. The facility's policy on incontinence, implemented in November 2022, stated that residents who are incontinent should receive appropriate treatment and services based on a comprehensive assessment. The failure to assess R701 for incontinence upon admission led to the deficiency noted in the report.
Failure to Address Changes in Range of Motion Leads to Contractures
Penalty
Summary
The facility failed to identify and implement interventions to address changes in range of motion (ROM) for resident R14, resulting in R14 developing contractures in three fingers. R14, admitted with diagnoses including atrial fibrillation, diabetes, and depression, was observed with the middle, ring, and little fingers bent down, making contact with the palm. Despite R14's complaint about the limited ROM, the clinical record showed no ROM goals or interventions in the care plan. The Occupational Therapist (OT) was unaware of the limitations until the observation on 4/23/24, where attempts to straighten the fingers were unsuccessful. The facility's policy on the Prevention of Decline in Range of Motion was not effectively implemented in this case. The OT evaluation on 4/23/24 revealed impaired ROM in R14's left hand, with specific degrees of extension limitations in the fingers. The facility's restorative documentation indicated a decrease in ROM noticed by a Certified Nursing Assistant (CNA) 2-3 weeks prior, but no appropriate actions were taken. Despite the facility's policy to provide interventions and exercises to maintain or improve ROM, the lack of timely assessment and intervention led to the development of contractures in R14's fingers.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered and documented per professional standards of practice for four residents. During a medication observation, an LPN left medications unattended at a resident's bedside while fetching water, which the LPN acknowledged was inappropriate. Another resident had an Albuterol inhaler from a hospital stay at their bedside without a current order, and the LPN did not remove it. Additionally, the LPN administered a different form of Aspirin than what was ordered for another resident. The Director of Nursing confirmed these actions were against the facility's medication administration policy. A resident reported experiencing phantom pain and stated that Tylenol helped, but it took hours to receive it after requesting. The resident's records showed no physician order for Tylenol or any pain medication. An RN admitted to giving Tylenol without a current physician order, which the Director of Nursing confirmed was against policy. The facility's job descriptions for RNs and LPNs require that all medications be administered as prescribed and documented properly.
Failure to Secure Portable Oxygen Tanks
Penalty
Summary
The facility failed to ensure an environment free from hazards, specifically regarding the storage of portable oxygen tanks. On multiple occasions, surveyors observed a portable oxygen tank in a resident's room propped up against the wall without being secured. This was first noted on 4/22/24 at 10:02 a.m. and was still observed in the same condition at 12:39 p.m. and again at 9:37 a.m. the following day. Additionally, a second oxygen tank was observed behind the nursing station, free-standing without any securing devices such as a caddie or cradle, on 4/22/24 at 2:38 p.m. When shown the unsecured oxygen tank in the resident's room on 4/23/24 at 9:40 a.m., the Nurse Manager acknowledged that all portable oxygen tanks should be stored appropriately with a caddie and not left leaning against a wall or free-standing. The facility's policy on oxygen safety, which was reviewed, mandates that cylinders be properly chained or supported in racks or other fastenings to prevent them from falling, whether they are connected, unconnected, full, or empty. This policy emphasizes the responsibility of all staff, residents, and visitors to report hazards or potential hazards to a supervisor or Maintenance Director as soon as practical.
Failure to Maintain Proper Medication Storage and Temperature Logs
Penalty
Summary
The facility failed to ensure expired medical supplies were removed, maintain a daily log of refrigerator temperatures, and provide refrigerated medication at the recommended temperature. During an observation of the second-floor medication storage room, it was found that the refrigerator was not locked, and the thermometer inside showed a temperature of 30 degrees Fahrenheit. A subsequent observation with the Director of Nursing revealed the refrigerator temperature was 28 degrees Fahrenheit, and the temperature log had not been documented for several days. The Director of Nursing confirmed that the midnight shift nursing staff was responsible for documenting refrigerator temperatures but had failed to do so. Additionally, random medical supplies pulled from the shelves were found to be expired, including urine catheters, tuberculin needles, and intravenous needles. The Director of Nursing acknowledged that these expired supplies should have been discarded and not stored past their expiration dates. The facility's Medication Storage Policy, which was reviewed, stated that all drugs and biologicals should be stored in locked compartments under proper temperature controls, and temperature levels should be recorded daily by the charge nurse or other designee. However, the facility failed to adhere to these policies.
Failure to Maintain Resident Dignity and Proper Care
Penalty
Summary
The facility failed to ensure dignity was maintained for three residents. Resident R38 was observed multiple times wearing a thin, stretchy light pink shirt without a bra, making her areola and nipples visible. Despite having severely impaired cognition and a care plan indicating a need for assistance with dressing, R38 did not have access to her bras. The Director of Nursing (DON) was unaware of the missing bras, and it was only after searching R38's belongings that several new bras were found, which were not listed on her inventory. This indicates a failure in maintaining the resident's dignity and ensuring proper clothing was available and used. Resident R43 was observed being pulled backwards in a geriatric chair by a CNA, which was acknowledged by the Nurse Supervisor as an unacceptable method of transport. Additionally, Resident R6 was observed multiple times with food debris and juice stains on their clothing, without a clothing protector, and remained in soiled clothing for an extended period. R6's care plan indicated a need for substantial assistance with upper body dressing and personal hygiene, which was not provided. These observations highlight a failure to maintain the dignity and cleanliness of the residents, as well as a lack of adherence to care plans and proper transport methods.
Failure to Clarify Resident's Advance Directive Code Status
Penalty
Summary
The facility failed to properly evaluate and clarify the advance directive code status for a resident (R4) who was receiving hospice services. R4, who had a medical history of chronic obstructive pulmonary disease (COPD), atrial fibrillation, and coronary artery disease, was readmitted to the facility and hospice care. Despite an advance directive dated 9/9/2023 indicating R4 elected for full resuscitation, the Electronic Medical Record (EMR) and face sheet identified R4 as Do Not Resuscitate (DNR). The Director of Nursing (DON) confirmed that the EMR incorrectly identified R4 as DNR, while the last advance directive indicated full code status. Further investigation revealed a hospice communication binder containing advanced directive paperwork dated 2/25/2024, which indicated R4's code status as DNR, signed by R4's Power of Attorney (POA), the facility's previous Limited Licensed Masters Social Worker (LLMSW), and the Facility Physician. However, the Corporate Licensed Bachelors Social Worker (LBSW) disclosed that R4 was never deemed incompetent and was not evaluated by two physicians for decision-making competency, making the DNR paperwork not legally binding. The code status for R4 was subsequently changed from DNR to Full Code. The facility's policy on Residents' Rights Regarding Treatment and Advance Directives requires the facility to identify, clarify, and review advance directives with the resident or legal representative, which was not adequately followed in this case.
Failure to Notify Responsible Party Before Hospital Transfer
Penalty
Summary
The facility failed to provide timely notification to a resident's responsible party before transferring the resident to the hospital. The resident, who was severely cognitively impaired and bedbound with multiple diagnoses including coronary artery disease, hypertension, diabetes, stroke, dementia, anxiety, and depression, required a hospital transfer due to a dislodged PEG tube. The Nursing Home Administrator and Director of Nursing confirmed that no notice of transfer was documented or provided to the resident's responsible party, as required by the facility's Transfer and Discharge Policy implemented on 11/1/2022.
Failure to Document Physician Acknowledgment of Medication Regimen Review
Penalty
Summary
The facility failed to document within the medical record for two residents that an identified irregularity from the medication regimen review (MMR) was acknowledged by the Physician/Prescriber. For Resident 19, who was admitted with conditions including stroke, dysphagia, dementia, anxiety, and depression, the MMR dated 2/12/24 recommended a gradual dose reduction (GDR) for Sertraline. However, the Physician/Prescriber did not acknowledge this recommendation, and the physician contacted could not confirm if the MMR was acknowledged. Similarly, for Resident 20, who was admitted with diagnoses including depression, anxiety, hypertension, renal dysfunction, and arthritis, two MMRs dated 2/12/24 and 4/15/24 recommended GDRs for Sertraline and Alprazolam. These recommendations were also not acknowledged by the Physician/Prescriber. Attempts to contact the responsible Nurse Practitioner for further information were unsuccessful by the end of the survey.
Failure to Obtain Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain a physician-ordered laboratory test for a resident, resulting in the potential for abnormal lab results to go unreported to the physician. The resident, who had diagnoses including cerebral infarction, paranoid schizophrenia, and neuromuscular dysfunction of the bladder, was observed not feeling well. A physician's evaluation noted the need for several lab tests, including a CBC, BMP, UA, and PSA level, due to the resident's complaint of dysuria and recent treatment for cystitis. However, the medical record did not contain results for the CBC, BMP, and PSA tests, and the nurse manager confirmed that these tests were not performed as ordered. The nursing progress note indicated that the lab technician was unable to draw blood and planned to return, but there was no follow-up to ensure the tests were completed. Additionally, the UA results, which showed abnormal findings, were not documented as reported to the physician. The facility's policy requires timely provision or obtaining of laboratory services when ordered by a physician, but this was not adhered to in this case, leading to a lapse in the resident's care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented and staff were educated on proper procedures for two residents. Resident 15, who had an indwelling urinary catheter, was observed multiple times without any EBP signage or personal protective equipment (PPE) in or near their room. Staff were also observed providing care to Resident 15 without donning PPE. The clinical record and care plan for Resident 15 did not mention EBP precautions, despite the resident's condition requiring them. The Infection Preventionist acknowledged the oversight and indicated a need for further staff education. Resident 27, who was on EBP due to cystitis, was observed being cared for by a Certified Nursing Assistant (CNA) who did not use gloves or a gown while handling dirty linens. Although PPE was available at the door, the CNA admitted they should have used it. The facility's policy on EBP was reviewed and confirmed that residents with indwelling medical devices or wounds should be on EBP, which includes the use of gowns and gloves during high-contact care activities.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide the required 80 square feet per resident for 16 of 20 multiple resident rooms and 100 square feet for 4 of 4 single resident rooms. This deficiency was observed during a survey on 4/22/24 at 2:00 pm. Specific rooms were noted to be below the required square footage, including rooms 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 201, 202, 203, 204, 205, 207, 208, 210, 211, and 214. Despite the inadequate space, interviews with residents revealed no complaints or dissatisfaction with their living conditions.
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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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