Optalis Health And Rehabilitation Of Allen Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Allen Park, Michigan.
- Location
- 9150 Allen Rd, Allen Park, Michigan 48101
- CMS Provider Number
- 235439
- Inspections on file
- 34
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Allen Park during CMS and state inspections, most recent first.
A resident with recent orthopedic injuries reported that an LPN delayed her admission and later confronted her in an aggressive manner, accusing her of making a report. After being suspended, the LPN reentered the facility and spoke to the resident, contrary to facility policy requiring immediate removal of staff under investigation for abuse. This resulted in a failure to protect the resident from intimidation and staff-to-resident abuse.
A resident with dementia and a history of falls was found to have a right hip fracture of unknown origin after being sent to the hospital for mental status changes. Despite facility policy requiring immediate reporting of such injuries, the incident was not reported to the State Agency, and staff interviews confirmed a lack of documentation and follow-through on required reporting procedures.
The facility did not maintain an Emergency Preparedness plan that was reviewed and updated annually, and failed to provide documentation of a written, geographically specific risk assessment for hazards identified in the emergency plan. Required documentation supporting compliance with an all-hazards approach, including missing residents, was not available for review, as confirmed by the Maintenance Director and Corporate Operations Director.
Surveyors identified multiple deficiencies in the maintenance and testing of the facility's automatic sprinkler system, including dirty sprinkler heads, missing escutcheon rings, recessed sprinkler heads, missing ceiling tiles, and improper storage of combustible materials within 18 inches of sprinkler heads. These issues were confirmed by the facility's Maintenance Director and Corporate Operations Director.
Surveyors observed multiple deficiencies including broken light bulb bases left in ceiling sockets, combustible materials stored too close to electrical panels, and exposed wiring behind a boiler. These issues were confirmed by facility leadership during the inspection.
A smoke detector in the north elevator room was found disconnected from its ceiling mount and hanging by wires, as observed during a facility inspection and confirmed by the Maintenance Director and Corporate Operations Director. This failure to maintain the fire alarm system in accordance with NFPA 70 and NFPA 72 requirements could affect 48 of 124 residents.
Surveyors observed that the facility did not display the required cautionary signage prohibiting oxygen use in the hair salon, as mandated by NFPA 99. This deficiency was confirmed by the Maintenance Director and Corporate Operations Director during the survey.
Surveyors identified that the facility did not maintain a comprehensive infection prevention and control program, with missing surveillance data, incomplete infection tracking, and lack of staff education. Additionally, several residents with indwelling devices or wounds were not properly identified for enhanced barrier precautions, with missing or unclear signage and inconsistent physician orders, contrary to facility policy.
The facility did not offer or administer seasonal influenza vaccines in a timely manner, as required by policy, to five residents. All affected individuals received the 2024-2025 influenza vaccine at the end of the vaccination period, rather than at the beginning of the season. Documentation and staff interviews confirmed that the delay was due to the vaccine not being offered at the appropriate time.
A resident with Parkinson's Disease and poor dental health, requiring substantial assistance with ADLs, did not have a dental care plan implemented despite documented dental needs and multiple oral surgery appointments. The DON confirmed the absence of a care plan addressing the resident's dental issues.
A resident dependent on staff for personal hygiene was found with long, jagged, and dirty fingernails over multiple days, despite a care plan requiring nail care twice weekly and as needed. The resident, who had moderate cognitive impairment and chronic medical conditions, had not refused care, and staff confirmed the lack of nail care.
A resident missed the majority of prescribed pregabalin doses for neuropathy due to staff not utilizing available backup medication and failing to follow up with the physician and pharmacy. Additionally, two residents with PICC lines did not receive proper line care, with discrepancies between documentation and observed dressing changes, and unclear or missing records for required line flushes and dressing change frequency.
A resident with a gastrostomy tube did not have their tube feed dressing changed daily as ordered by the physician, with the dressing remaining unchanged for ten days. An LPN confirmed the lapse, and the DON stated that the expectation was for nurses to follow the daily dressing change order. Facility policy also required adherence to physician orders for tube feeding management.
A resident with ESRD on hemodialysis was repeatedly observed with a large cup of water or ice at the bedside, despite physician orders and dialysis center instructions for strict fluid restriction. The care plan and Kardex did not reflect the fluid restriction, and staff interviews confirmed that the order was not communicated or implemented, resulting in a lack of coordination between the facility and the dialysis center.
A resident with moderate cognitive impairment and multiple medical conditions was found with prescription medication left unattended at the bedside during a med pass. An LPN discovered the pills, and the resident reported that this occurs frequently because staff say they cannot wake her. Facility policy and the DON confirmed that medications should not be left at the bedside and must be secured.
A resident with Parkinson's Disease requiring significant ADL assistance did not receive timely dental care after multiple canceled oral surgery appointments for full extractions. Staff failed to reschedule or ensure the resident received needed dental services, despite facility policy requiring assistance with routine and emergency dental care.
A resident with a gastrostomy tube did not receive daily dressing changes as ordered, and staff documented wound care as completed on days when it was not performed. An LPN confirmed the documentation was inaccurate and discussed the issue with the RN involved. The DON stated that records are expected to be accurate and treatments provided as ordered.
A resident with multiple health conditions experienced verbal abuse from a CNA, who used derogatory language after refusing to provide adequate care. The incident was witnessed by a nurse, leading to the CNA's termination. The facility's investigation confirmed the abuse, violating their policy against verbal abuse.
A resident with a history of spinal issues and leg amputation fell out of bed due to the absence of a proper bed frame extender. The resident, who required assistance with toileting, was in a 42-inch bed without extenders, causing the mattress to slip during care by a CNA. The facility's maintenance confirmed the lack of extenders, and the DON agreed this contributed to the fall.
A facility failed to use the correct sanitizing product to kill C. diff spores, risking infection spread. A housekeeper used a multi-purpose cleaner instead of bleach in a resident's room under transmission-based precautions. The Infection Preventionist and Housekeeping Supervisor confirmed the error, and the Nursing Home Administrator expected proper product use.
A facility failed to properly complete Advance Directive documentation for a resident with a DNR order. The DNR form was not signed by witnesses on the same date as the guardian, as required by policy. This oversight could lead to the resident's medical care preferences not being followed. The resident had mild cognitive impairment.
A facility failed to complete an annual OBRA Level II Evaluation for a resident, potentially leading to unmet mental health services. The resident, with diagnoses including adjustment disorder, dementia, bipolar disorder, and major depressive disorder, had a Level II PASARR due for renewal, which was not submitted. The NHA stated PASARRs should be completed upon admission, a change in condition, and annually, but no additional documentation was provided during the exit conference.
The facility failed to provide wound care as ordered for a resident with skin conditions, resulting in unmet treatment needs. Additionally, the facility did not follow up on pharmacist recommendations for a resident's medication regimen in a timely manner. Furthermore, antihypertensive medication was not consistently held per physician's order, and blood pressure was not checked prior to administration for two residents, leading to unmet care needs.
A resident at high risk for pressure ulcers was observed with their heel resting directly on the mattress, despite care plans requiring heel lift boots. Staff inconsistencies and lack of documentation on boot application and refusals were noted. The resident had a history of severe cognitive impairment and previous pressure sores, increasing their risk. The facility's policy on skin and wound care was not adequately followed, contributing to the deficiency.
The facility failed to obtain weekly weights and perform timely nutrition reviews for two residents at high nutritional risk. One resident, with fluctuating weight due to multiple health conditions, had only one weight recorded over a month despite recommendations for weekly monitoring. Another resident, reliant on enteral feeding, did not receive the required monthly follow-up. The Registered Dietitian acknowledged the oversight, and the Director of Nursing confirmed the expectations for timely assessments and weight measurements.
A medication error rate of 7.41% was identified when an LPN administered incorrect doses of Flonase and provided a PRN breathing treatment without an order to a resident with COPD and asthma. The resident's orders were not followed, leading to the deficiency.
The facility failed to provide two residents with influenza and/or pneumococcal vaccinations and the necessary education. The residents, one with Multiple Sclerosis and Parkinson's Disease and another with Heart Failure, lacked documentation in their EHRs indicating that the vaccines were offered or contraindicated. The DON confirmed that the residents and/or their guardians should have been educated and offered the vaccines, as per the facility's policy.
A facility failed to ensure a resident with Multiple Sclerosis and Parkinson's Disease was provided COVID-19 vaccination and education, leading to potential risk for COVID-19 spread. The resident's records lacked documentation of vaccination or refusal, as confirmed by the Infection Preventionist and DON. Facility policy requires offering the vaccine and documenting education and vaccination status.
The facility had six rooms below ground level, potentially risking water damage. These rooms, observed during a survey, had windows with a line of sight looking up and out. The Housekeeping and Laundry Director confirmed the rooms had been like this for years but were not in use. No water damage was noted.
A resident with a history of stroke and left-sided weakness, requiring a two-person assist for bed mobility, rolled out of bed and sustained a skin tear during a bed bath when only one CNA was present. The CNA was unaware of the two-person assist requirement, leading to the fall and injury.
A resident with Dementia and Hemiplegia was not provided timely incontinence care, resulting in prolonged discomfort and potential skin issues. Despite the facility's policy requiring checks every two hours, the resident was found with a heavily soiled brief and wet bedding, and staff did not attend to the resident until later in the morning.
The facility failed to implement a comprehensive care plan for a resident with vision impairment and chronic urinary tract infections. Despite the resident's history of falls and recent treatment for a UTI, the care plan did not address these issues. Interviews with staff confirmed the absence of necessary care plan entries, and a vision exam indicated severe blurry vision, which was also not included in the care plan.
A facility failed to obtain a timely physician's order for a resident with an ileostomy, resulting in unmet care needs. The resident was admitted with severe cognitive impairment and required specific ostomy care, but the care plan and physician's orders were not initiated until two weeks after admission. The DON confirmed the lack of necessary documentation and monitoring during this period.
Failure to Prevent Staff-to-Resident Abuse and Intimidation
Penalty
Summary
A resident with a history of right tibia fracture, lumbar vertebra fracture, and injuries from a motor vehicle accident was admitted to the facility and reported an incident involving an LPN. The resident stated that the LPN did not want to admit her, causing a delay in her admission. The following day, the LPN entered the resident's room and accused her of reporting the LPN, using an aggressive tone that made the resident feel uneasy and fearful. The resident had intact cognition, as indicated by a BIMS score of 14/15. Facility records and interviews confirmed that after being suspended pending investigation, the LPN reentered the building and confronted the resident, despite the expectation that suspended staff leave the premises immediately and not return until notified by a supervisor. The facility's abuse policy requires immediate removal of alleged abusers and protection of residents from all forms of abuse, including intimidation and retaliation. The LPN's actions violated these policies, resulting in a failure to prevent staff-to-resident abuse and to protect the resident from psychosocial harm.
Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a fracture of unknown origin to the State Agency (SA) for one resident, as required by both regulation and facility policy. The resident, who had a history of dementia and falls, experienced a fall during therapy, which was documented with no injury or pain at the time. Over a month later, the resident's family requested an x-ray due to complaints of pain, but the x-ray was negative for acute fracture. Subsequently, the resident was sent to the hospital for mental status changes, where a right hip fracture of unknown origin was discovered. There was no documentation of any additional falls after the initial incident in therapy. Interviews with staff revealed that the RN who ordered the x-ray did not inquire about the timing of any new fall, and the DON confirmed that an investigation was initiated but not reported to the SA. The NHA was unaware of the incident until the survey and acknowledged that the fracture should have been reported. The facility's abuse policy requires immediate reporting of injuries of unknown source to the SA, but this was not followed in this case.
Deficient Emergency Preparedness Plan and Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required by regulations. Specifically, the facility did not provide evidence of a written, geographically specific risk assessment for hazards identified in their emergency plan. The plan was also required to utilize an all-hazards approach, including consideration of missing residents, but documentation supporting compliance with these requirements was not available for review. During the survey conducted on June 6, 2025, at 2:30 PM, the surveyor requested documentation of the facility-based and community-based risk assessment. The facility was unable to present the required documentation by the time of the survey exit. These findings were confirmed in interviews with both the Maintenance Director and the Corporate Operations Director during the record review process.
Plan Of Correction
E006 Element # 1: The facility emergency preparedness plan was updated using a geographically specific risk assessment. Element # 2: Current residents have the potential to be affected by the deficient practice. The facility Emergency Preparedness plan was reviewed, and necessary updates were made based on the geographically specific risk assessment. Element # 3: The policy, Emergency Operations Plan, was reviewed and deemed appropriate. The maintenance department and IDT were re-educated on the policy, Emergency Operations Plan, with emphasis on a geographically specific risk assessment. Element # 4: The Administrator and/or designee will conduct random audits of the emergency preparedness plan once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to provide proper maintenance and testing of its automatic sprinkler system as required by NFPA 25. During an inspection, surveyors observed multiple instances of dirty sprinkler heads in various locations, including the Med "C" Nurse Storage Room, Eagle Room, Med "C" Dining Room, Employee Lounge, and Room 107. Additionally, a sprinkler head was found missing an escutcheon ring in the Housekeeping Managers Office, and three sprinkler heads in the corridor by the 1st floor elevator were recessed into the ceiling tile up to the deflector. There were also observations of missing ceiling tiles and a ceiling tile with a large annular space at a light fixture, which could compromise the effectiveness of the sprinkler system. Further deficiencies included combustible stock stored within 18 inches of sprinkler heads in the Business/Activities Office storage cage and the kitchen pantry, which violates clearance requirements for sprinkler systems. These findings were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
K 353 Element # 1 The sprinkler heads in the Med C Nurse Storage Room, Eagle Room, Med C Dining Room, Employee Lounge and Room 107 were cleaned. The combustible stock on the Business/Activities Storage Cage and in the Kitchen Pantry was removed to be 18 inches from the ceiling and sprinkler heads. The missing ceiling tile in the Janitor Room was replaced. The escutcheon ring on the sprinkler in the Housekeeping Manager's office was replaced. The ceiling tile in the Housekeeping Manager's Office was replaced. The 3 recessed sprinkler heads in the corridor by the 1st floor elevator have been properly installed. Element # 2 Current residents have the potential to be affected by the deficient practice. All sprinkler heads were evaluated to ensure cleanliness and proper installation. Any sprinklers found to be out of compliance will be corrected. All ceiling tiles were evaluated for compliance. Any ceiling tiles that were out of compliance are to be replaced. Element # 3 The maintenance department was re-educated on sprinkler head cleanliness, proper installation of sprinkler heads and missing/broken ceiling tiles. Element # 4 The Administrator and/or designee will conduct random audits of the sprinkler heads and ceiling tiles once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Noncompliance with Gas and Electrical Safety Standards
Penalty
Summary
The facility failed to ensure that equipment using gas or gas-related piping complied with NFPA 54 and that electrical wiring and equipment complied with NFPA 70. During observations, surveyors found two ceiling-mounted light sockets with the bases of broken light bulbs still inside the sockets in the Business/Activities Supply Cage. Combustible stock items were stored within three feet of electrical panels in both the Laundry and Sump Pump Room. Additionally, a Greenfield conduit was found displaced, exposing inner wires at the plug to the relay in the back of a boiler in the North Boiler Room. These deficiencies were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation.
Plan Of Correction
K 511 Element # 1 The (2) ceiling mounted light sockets in the Business/activities Supply cage with broken light bulbs, were repaired. The items stored in the Laundry Room within 3 of the electrical panel were removed. The Greenfield Conduit in the North Boiler Room was repaired. The combustible items within 3 of electrical panel in the sump pump room were removed. Element # 2 Current residents have the potential to be affected by the deficient practice. The facility's electrical equipment was evaluated to ensure proper maintenance. Any deficiencies found were corrected. Element # 3 The Maintenance Department was re-educated on properly maintained electrical equipment. Element # 4 The Administrator and/or designee will conduct random audits of the emergency preparedness plan x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Disconnected Smoke Detector in Elevator Room
Penalty
Summary
During an observation on June 6, 2025, it was found that the smoke detector in the north elevator room was disconnected from its ceiling mount and was hanging by its wires. This issue was identified during a facility inspection and was confirmed through interviews with both the Maintenance Director and the Corporate Operations Director at the time of observation. The deficiency reflects a failure to ensure the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72 standards. This condition could potentially affect 48 of the 124 residents in the facility in the event of a fire. Records of system acceptance, maintenance, and testing were required to be readily available, but the direct observation of the disconnected smoke detector indicated non-compliance with these requirements.
Plan Of Correction
K 345 Element # 1 The smoke detector in the north elevator room was reconnected to the ceiling mount. Element # 2 Current residents have the potential to be affected by the deficient practice. All smoke detectors in the facility were evaluated to ensure proper mounting to the ceiling. Element # 3 The Maintenance Department was re-educated on proper mounting of smoke detectors. Element # 4 The Administrator and/or designee will conduct random audits of the smoke detectors x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with properly mounted smoke detectors. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Missing Required Oxygen Prohibition Signage in Hair Salon
Penalty
Summary
The facility failed to comply with NFPA 99 requirements regarding the storage and handling of nonflammable gases. During an observation, it was found that the required cautionary signage, specifically a sign stating "NO OXYGEN ALLOWED" or similar wording prohibiting the use of oxygen, was not displayed in the hair salon. This signage is necessary to alert staff and visitors to the presence of oxidizing gases and to prohibit activities that could increase fire risk. This deficiency was confirmed through interviews with both the facility Maintenance Director and the Corporate Operations Director at the time of the observation. The lack of appropriate signage in the designated area represents a failure to meet established safety standards for gas storage and handling within the facility.
Plan Of Correction
K 923 Element # 1 A No Oxygen Allowed sign was placed on the Beauty Salon door. Element # 2 Current residents have the potential to be affected by the deficient practice. A facility audit was conducted to ensure the proper storage of oxygen cylinders with proper signage related to oxygen are in place. Any found deficiencies were corrected. Element # 3 The maintenance department was re-educated on proper storage of oxygen cylinders with proper signage in place. Element # 4 The Administrator and/or designee will conduct random audits of oxygen storage and proper signage x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with oxygen storage. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Infection Control Program and Enhanced Barrier Precautions Deficiencies
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by federal regulations. The Infection Control Preventionist (ICP) had not compiled infection control data for several months, including April and May, and there was no documentation of monthly summaries, infection rates, lists of facility infections, mapping for trends or outbreaks, line listings for antibiotic usage, pharmacy or laboratory reports, departmental surveillance, or staff education for October, November, or December of the previous year. For January, February, and March, only partial data was available, and the line listings did not demonstrate that prescribed antibiotics met McGeer's Criteria. The Director of Nursing acknowledged that the infection control program had not been comprehensively maintained by the previous ICP. Additionally, the facility failed to ensure proper identification and implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. Multiple residents with PICC lines or urinary catheters did not have appropriate EBP signage outside their rooms, and in some cases, EBP orders were missing or delayed in the clinical records. Observations revealed that signage, when present, did not specify which resident in shared rooms was on EBP, leading to confusion and lack of clarity for staff and visitors. Some residents with qualifying conditions for EBP had no signage at all, while others had signage that did not accurately reflect their status. Facility policy required that residents with wounds or indwelling medical devices be placed on EBP upon admission, with physician orders and clear signage indicating the specific resident on precautions. However, the observed practices did not align with these policies, as evidenced by missing or unclear signage, delayed or absent orders, and inconsistent application of EBP. These deficiencies were confirmed through interviews with the ICP and review of facility policies and resident records.
Plan Of Correction
F 880 Infection Control Deficient Practice #1 ELEMENT #1: Infection control program data for April & May 2025 was completed. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. An infection control program that includes preventing, identifying, reporting, investigating, and monitoring and surveillance infections was put into place for June 2025. ELEMENT #3: The policy, "Infection Control Surveillance," was reviewed and deemed appropriate. The policy remains in place. The Infection Preventionist was re-educated on the policy, "Infection Control Surveillance," with emphasis on data collection and tracking. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents with identified and/or potential infections to ensure substantial compliance with infection control data tracking. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025 --- F 880 Infection Control Deficient Practice #2 ELEMENT #1: Enhanced Barrier Precautions were put into place for residents #126, 233, 235, 4, 234, 85, and 30. ELEMENT #2: Current residents requiring Enhanced Barrier Precautions have the potential to be affected by the deficient practice. Current residents requiring Enhanced Barrier Precautions were evaluated to ensure Enhanced Barrier Precaution signage was in place and orders were entered into the electronic medical record. Any resident identified as needing Enhanced Barrier Precautions had proper signage placed and orders entered into the electronic medical record. ELEMENT #3: The policy, "Enhanced Barrier Precautions," was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses and Registered Nurses were re-educated on the policy, "Enhanced Barrier Precautions," with emphasis on proper signage and orders. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents needing enhanced barrier precautions (EBP) to ensure substantial compliance with enhanced barrier precautions, including signage and MD orders. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Delayed Administration of Influenza Vaccines
Penalty
Summary
The facility failed to ensure that seasonal influenza vaccines were offered and administered in a timely manner to five residents reviewed for influenza immunizations. According to the facility's policy, influenza vaccinations should be offered annually between September 1st (or when vaccines become available) and March 31st. However, documentation showed that all five residents received the 2024-2025 influenza vaccine on March 25th, which was at the end of the designated vaccination period. The records indicated that these residents had been admitted or re-admitted to the facility prior to the administration date, but the vaccines were not offered or given at the beginning of the influenza season as required. An interview with the DON revealed awareness that the former Infection Control Preventionist did not offer the vaccine at the start of the 2024-2025 influenza season. The DON stated that the immunizations were administered in March after discovering the oversight. The clinical records for each resident confirmed the delayed administration of the influenza vaccine, with no evidence that the immunizations were offered or provided earlier in the season as per facility policy and federal requirements.
Plan Of Correction
F 883 Influenza & Pneumococcal Immunizations ELEMENT #1 Residents # 28, 24, 26, 19 and 12 continue to reside within the facility and Influenza vaccinations were administered on 3/25/25 with no negative outcomes. Facility infection control was reviewed and there has not been any confirmed cases of Influenza from March through June 2025. ELEMENT #2 Residents residing within the facility will be educated, offered, and vaccinated with the Influenza vaccine for 2025/2026 when made available and dispensed by pharmacy. ELEMENT #3 The policy, Influenza Vaccine was reviewed and deemed appropriate. The policy, Influenza Vaccine remains in place. The Infection Control Nurse was re-educated on the policy, Influenza Vaccine with emphasis on offering vaccinations in a timely manner. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with offering vaccinations. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Implement Dental Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive dental care plan for a resident who required significant dental services. The resident, who was admitted with Parkinson's Disease and had intact cognition, was observed to have crooked and uneven teeth and reported having broken teeth. Although the resident had seen a dentist and had appointments scheduled for oral surgery, there was no evidence in the care plan that addressed the resident's dental needs. Documentation in the medical record indicated plans for a full mouth extraction and the resident's desire for dentures, but these needs were not reflected in the care plan. The resident required substantial to maximal assistance with activities of daily living and had a documented history of poor dental health. Despite multiple dental appointments and referrals, the facility did not develop or implement a dental care plan as required by their own policy and federal regulations. The DON confirmed that the facility should have been aware of the resident's dental issues and that a care plan should have been in place to address these needs.
Plan Of Correction
F 656 Comprehensive Care Plan ELEMENT #1 Resident #19 care plan was updated with a dental care plan. ELEMENT #2 Current residents followed by Health Drive for dental services have the potential to be affected by the deficient practice. Current residents followed by Health Drive were assessed for dental health problems. Any resident identified with dental health problems had a dental care plan reviewed, updated or created. ELEMENT #3 The policy, Care Plan-Comprehensive Revision, was reviewed and deemed appropriate. The policy, Care Plan-Comprehensive Revision remains in place. The IDT was re-educated on the policy, Care Plan-Comprehensive Revision, with emphasis on dental care plans. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits on 5 residents weekly to ensure substantial compliance with dental care plans. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for personal hygiene was observed to have long, jagged, and dirty fingernails with debris, and reported needing their nails cut. The resident stated they had received a bed bath over the weekend, but their fingernails remained untrimmed and unclean over several days of observation. Staff confirmed the resident's nails were long and dirty, and the resident agreed to have them trimmed when asked. The resident's medical record indicated diagnoses including venous insufficiency and chronic ulcers, and a moderate cognitive impairment, requiring dependent assistance for personal hygiene. The care plan specified nail care was to be provided twice a week on shower days and as needed, but there was no documentation of refusals for nail care or bed baths in the electronic medical record for the relevant period.
Plan Of Correction
F 677 ADL Element #1 Resident #41 was provided nail care. Element #2 Current residents have the potential to be affected by the deficient practice. Current residents were assessed for the need of nail care. Any residents without nail care completed were provided nail care and documented in the electronic medical record. Refusals and preferences were documented in the electronic medical record and care plan was updated accordingly. Element #3 The policy, Nail Care Policy, has been reviewed and deemed appropriate. The policy remains in place. CNA s, Licensed Practical Nurses & Registered Nurses were re-educated on the policy for Nail Care Policy with emphasis on routine cleaning and inspection. Element #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with nail care. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Missed Medication Administration and Inadequate PICC Line Care
Penalty
Summary
The facility failed to ensure that a resident received their prescribed neuropathy medication, pregabalin, as ordered by the physician. Upon admission, the resident had an order for pregabalin 75 mg twice daily, but missed 18 out of 21 scheduled doses over a period of approximately ten and a half days. Documentation on the medication administration record indicated the medication was held due to reasons such as awaiting pharmacy delivery, dosage not available in backup, and not in cart. However, the facility's backup medication supply did contain pregabalin in 25 mg and 50 mg tablets, which were not utilized. The Director of Nursing confirmed that staff should have checked the backup supply and followed up with the physician and pharmacy given the prolonged period without medication. The facility also failed to provide proper care and maintenance for PICC lines for two residents. One resident was observed with a PICC line dressing that had multiple layers of tape, with an illegible date, and was unable to recall when the dressing was last changed. Review of the clinical record showed the resident had orders for PICC line flushes, but the medication administration record did not allow staff to sign off on these flushes. Additionally, documentation indicated a dressing change had occurred, but this was not consistent with the observed condition of the dressing. For the second resident with a PICC line, the dressing was observed to be dated from several days prior, despite documentation indicating that dressing changes had been performed more recently. The resident was unsure of when the dressing was last changed and questioned the frequency of required changes. The facility's policy on catheter care did not specify the required frequency for PICC line dressing changes, and national guidelines recommend weekly changes or more frequently if needed.
Plan Of Correction
F 684 Deficient Practice #1 ELEMENT # 1 Resident #30 pregabalin was ordered and received from the pharmacy. ELEMENT # 2 Current residents admitted within the last 7 days, electronic medication administration records were reviewed for medications that were held due to medication unavailability. Any medications identified as unavailable; the pharmacy was contacted to resolve the unavailability. ELEMENT # 3 The policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, was reviewed and deemed appropriate. The policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, remains in place. Licensed Practical Nurses & Registered Nurses were re-educated on the policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, with emphasis on obtaining medications from the emergency back-up supply. ELEMENT # 4 The Director of Nursing and/or designee will conduct random audits of 5 newly admitted residents electronic medication administration records to ensure unavailable medications are being pulled from back up and or reviewed by the physician. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025 F 684 Deficient Practice #2 ELEMENT # 1 Resident #30 & #233 PICC line dressings were changed. ELEMENT # 2 Current residents with PICC lines have the potential to be affected by the deficient practice. Current residents with PICC lines electronic medical records were reviewed to identify residents for PICC line dressing changes. Any residents without dressing changes, were changed and documented in the electronic medical record. ELEMENT # 3 The policy, Catheter Insertion and Care, was reviewed and deemed appropriate. The policy, Catheter Insertion and Care, remains in place. Licensed Practical Nurses and Registered Nurses were re-educated on the policy, Catheter Insertion and Care with emphasis on PICC line dressing changes. ELEMENT # 4 The Director of Nursing and/or designee will conduct random audits of 5 residents with PICC lines to ensure substantial compliance with PICC line dressing changes. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Perform Daily Tube Feed Dressing Changes per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube reported that staff were not changing their tube feed dressing as required. Observation confirmed that the dressing was dated from ten days prior, and a Licensed Practical Nurse (LPN) acknowledged that the dressing had not been changed since that date. The LPN stated that the dressing should be changed daily during the night shift and recognized the risk for infection if the site is not kept clean. Review of the resident's electronic medical record showed a physician order specifying that the enteral tube site should be cleansed with soap and water, rinsed, allowed to air dry, and have split gauze applied, dated, and initialed every night shift. The Director of Nursing (DON) confirmed that the expectation was for nurses to follow these physician orders and that the dressing should have been changed daily. Facility policy also required tube feedings to be managed according to physician orders and current clinical standards of practice.
Plan Of Correction
F 693 Tube Feeding Element #1: Resident #69 dressing was changed. Element #2: Current residents with gastrostomy tubes have the potential to be affected. Current residents with gastrostomy tubes were assessed to ensure that dressings were changed. Any dressing not in place or in need of change was completed. Current residents with gastrostomy tubes' electronic medical records were reviewed to ensure that dressing change orders were in place. Any resident without orders for dressing change orders was entered into the electronic medical record. Element #3: The policy, Tube Feeding - Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy remains in place. Registered Nurses & Licensed Practical Nurses were re-educated on the policy for Tube Feeding - Formula Administration, Flushing, and Unclogging, with emphasis on gastrostomy tube dressings. Element #4: The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with tube feeding dressing changes. Audits will be conducted weekly for four weeks, then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Coordinate Dialysis Fluid Restrictions
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the contracted dialysis center for a resident with end stage renal disease (ESRD) who required hemodialysis. Despite physician orders specifying "No bedside water and one beverage per meal tray" per the dialysis clinic, the resident was repeatedly observed with a 20 oz. cup of water or ice at the bedside, which the resident could access and consume. Documentation from the dialysis center indicated ongoing concerns about excessive fluid intake, including notes that the resident was gaining more fluid than could be removed during dialysis, and specific requests to reduce fluid intake and monitor liquid foods and snacks. The care plan and Kardex did not reflect the fluid restriction order, and interventions included encouraging fluid intake, which conflicted with the dialysis center's instructions. Interviews with facility staff, including an LPN/Unit Manager and the DON, confirmed that the fluid restriction was not communicated or implemented in the resident's care plan or Kardex, and that the necessary coordination with the dialysis center and facility registered dietitian had not occurred. The DON acknowledged the need for consultation between the facility RD and the hemodialysis center, which had not been done. No additional documentation or information was provided by facility leadership during the exit conference regarding this deficiency.
Plan Of Correction
F 698 Dialysis Fluid Restrictions ELEMENT #1 A fluid restriction order was entered into the electronic medical record for Resident #15. ELEMENT #2 Like residents that receive dialysis treatment; electronic medical records were reviewed to ensure that residents needing fluid restrictions had orders entered into the electronic medical record. Any resident identified to need fluid restrictions had orders entered into the electronic medical record. ELEMENT #3 The policy, Fluid Restrictions was reviewed and deemed appropriate. The policy, Fluid Restrictions remains in place. Registered Nurses, Licensed Practical Nurses and Registered Dietician were re-educated on the policy, Fluid Restrictions, with emphasis on residents receiving dialysis treatment and fluid restrictions. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents receiving Dialysis treatments to ensure substantial compliance with fluid restrictions if ordered. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when prescription medication was found unsecured at a resident's bedside during a morning medication pass. An LPN discovered a cup containing two pills (Faxiga and Levothyroxine) on the resident's bedside table, with no knowledge of who placed them there. The resident, who has a history of chronic obstructive pulmonary disease, dementia, psychotic disorder, schizoaffective disorder, major depressive disorder, type two diabetes mellitus, and generalized anxiety, was observed reaching for the medication and stated that pills are often left at the bedside because staff claim they cannot wake her up. The resident's records indicated moderately impaired cognition and no completed self-administration assessment. Facility policy requires all medications to be stored in locked compartments or under the direct observation of the person administering them. The DON confirmed that leaving medication at the bedside is unsafe and against facility policy, as it could allow unauthorized access. The medication in question was scheduled for administration at 6 a.m. and should not have been left unattended at the resident's bedside.
Plan Of Correction
F 761 Medication Storage ELEMENT #1: Medication was removed and properly disposed of from Resident #21's room. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. Current residents' rooms were evaluated for proper medication storage. Any medications not properly stored were properly stored and/or disposed of. ELEMENT #3: The policy, Medication and Treatment Cart Storage policy, was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses & Registered Nurses were re-educated on the policy, Medication and Treatment Cart Storage, with emphasis on proper medication storage. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents' rooms to ensure substantial compliance with medication storage. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Timely Dental Services
Penalty
Summary
A deficiency occurred when a resident with Parkinson's Disease, who required substantial to maximal assistance with activities of daily living and had intact cognition, did not receive timely dental care. The resident had a history of broken teeth and had been waiting for dentures for an extended period. Medical records showed that the resident was referred for full dental extractions and had multiple oral surgery appointments scheduled, but the procedures were not performed. After the last missed appointment, no new appointment was scheduled. Interviews revealed that each time the resident was taken to an appointment, the family did not show up, resulting in cancellations. Staff did not follow up to reschedule the procedure or ensure the resident received the necessary dental care. The DON confirmed that staff should have scheduled another appointment and could have accompanied the resident for assistance, acknowledging that the resident did not receive dental care in a timely manner. The facility's policy required assistance in obtaining routine and emergency dental care, which was not met in this case.
Plan Of Correction
F 791 Dental Services ELEMENT #1 Resident #19 had a dental appointment made for 6/24/25. ELEMENT #2 Current residents followed by Health Drive have the potential to be affected by the deficient practice. Current residents followed by Health Drive were assessed for additional dental service needs. Any resident in need of dental services was referred to Health Drive. Any resident needing additional dental care, an appointment was made for. ELEMENT #3 The policy, Dental Services has been reviewed and deemed appropriate. The policy, Dental Services remains in place. The social work department and ward clerks were re-educated on the policy, Dental Services with emphasis on follow-up dental appointments. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with dental services being scheduled. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Ordered Tube Feed Dressing Changes and Accurate Documentation
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube reported that staff were not changing their tube feed dressing as required. Upon observation, the tube feed dressing was found to be dated from over a week prior, indicating it had not been changed daily as ordered. The resident confirmed that the dressing had not been changed, and a Licensed Practical Nurse (LPN) verified that the dressing should be changed every night shift to reduce the risk of infection. Further review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed discrepancies. The records indicated that wound care and bandage changes had been documented as completed on several days when, in fact, the last dressing change had occurred much earlier. The LPN acknowledged that these entries were incorrect and stated that documentation should only occur after care has been provided. The LPN also reported discussing the issue of falsification of records with the Registered Nurse (RN) who had made the entries. The resident's medical history included dysphagia and the presence of a gastrostomy tube, with physician orders specifying daily site care and dressing changes. The Director of Nursing (DON) confirmed that the facility's expectation is for medical records to be accurate and for residents to receive the treatments as ordered. The failure to provide daily dressing changes and the inaccurate documentation led to the identified deficiency.
Plan Of Correction
F 842 Accurate Medical Record ELEMENT #1 Resident #69 dressing was changed and properly documented in the electronic medical record. ELEMENT #2 Current residents with enteral tubes have the potential to be affected by the deficient practice. Current residents with enteral tubes dressings were evaluated to determine if they were changed timely. Any dressing not changed was changed and appropriately documented in the electronic medical records. ELEMENT #3 The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, and the policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, remains in place. Registered Nurses & Licensed Practical Nurses were re-educated on the policy for Tube Feeding- Formula Administration, Flushing, and Unclogging with emphasis on enteral tube dressing changes and documentation. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with enteral tube dressing changes and documentation. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to prevent verbal abuse for a resident, resulting in staff-to-resident verbal abuse. The incident involved a resident who was readmitted to the facility with multiple diagnoses, including chronic respiratory failure, quadriplegia, and major depressive disorder. The resident was cognitively intact, as indicated by a BIMS score of 15/15, and was dependent on staff for toileting and hygiene. The incident occurred when the resident activated the call light for assistance, and the Certified Nurse Aide (CNA) initially responded but did not return promptly, leading to a delay in care. When the CNA returned after being called from a lunch break, the resident requested additional cleaning, which the CNA refused, leading to a verbal altercation. The CNA used derogatory language towards the resident, calling her a "Fucking bitch" and telling her to "wipe your own ass." This exchange was overheard by a floor nurse, who reported the incident to a supervisor. The CNA was subsequently terminated from employment following the incident. Interviews with the resident, the CNA, and nursing staff confirmed the occurrence of verbal abuse. The resident described the CNA's attitude and refusal to provide adequate care, while the CNA denied the allegations, claiming the resident cursed first. However, the floor nurse corroborated the resident's account, having overheard the abusive language. The facility's investigation confirmed the verbal abuse, which violated the facility's abuse policy that prohibits verbal abuse, including harassment and insulting language.
Failure to Provide Proper Bed Frame Extender Leads to Resident Fall
Penalty
Summary
The facility failed to provide a proper bed frame extender for a resident, resulting in the resident rolling out of bed during patient care. The incident involved a resident with a history of acquired absence of the right leg below the knee, spinal stenosis, and lumbar radiculopathy. The resident, who had intact cognition and required partial to moderate assistance with toileting, was observed in a 42-inch bed without the necessary bed frame extenders. During an interaction with a CNA, the resident rolled out of bed because the mattress slipped off the bed frame, which lacked extenders to secure it. The incident report indicated that the resident slipped out of bed while being repositioned by a CNA, as the mattress did not fit securely within the bed frame. The CNA confirmed that the mattress flipped and the resident began sliding out of bed. Maintenance records showed that the bed did not have the required extenders at the time of the incident, and the Director of Nursing acknowledged that the absence of extenders contributed to the fall. The facility's Fall Management Guidelines identified extrinsic factors, such as the physical environment, that could increase the risk of falls.
Improper Sanitization for C. diff Infection
Penalty
Summary
The facility failed to ensure the use of a proper sanitizing product to kill Clostridium difficile (C. diff), a bacteria that can cause diarrhea, potentially affecting all residents. On June 25, a resident in a specific room was placed on transmission-based precautions due to a C. diff infection. Despite signage indicating the need for such precautions, a housekeeper entered the room without donning appropriate personal protective equipment, except for gloves, and used a multi-purpose cleaner, Xcelente, instead of bleach, which is required to kill C. diff spores. The housekeeper was unaware of the need to use bleach until informed later. The Infection Preventionist confirmed that bleach is necessary to kill C. diff spores and expressed concern about the potential spread of the infection due to improper cleaning. The Housekeeping Supervisor acknowledged that the wrong product was used, and the Nursing Home Administrator expected the correct products to be used. During the exit conference, no additional documentation or information was provided by the Nursing Home Administrator or the Director of Nursing.
Failure to Properly Complete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the proper completion of Advance Directive information for a resident, which could potentially result in the resident's medical care preferences not being followed. The resident had a Do Not Resuscitate (DNR) order, which was signed by the guardian and later by the physician and two witnesses. However, the dates of the signatures by the witnesses did not match the date of the guardian's signature, as required by the facility's policy. The policy mandates that the DNR form must be fully completed and signed by the resident or their legal representative, two witnesses, and a physician for it to be valid. Until then, the resident is considered Full Code by default. The resident in question had mild cognitive impairment with a BIMS score of 13 out of 15.
Failure to Complete Annual OBRA Level II Evaluation
Penalty
Summary
The facility failed to complete an annual OBRA Level II Evaluation for one of the seven residents reviewed for PASARRs, which could result in unmet mental health services. The clinical record review revealed that the resident was initially admitted and later readmitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment documented moderate cognitive impairment. The most recent Level II PASARR was dated 3/21/23, and it was due for renewal on 3/21/24. However, the facility did not submit a new Level II PASARR as required. During a review with the Social Worker, it was noted that the local community mental health services had modified the document on 3/21/23, indicating the need for a new submission. The Nursing Home Administrator stated that PASARRs should be completed upon admission, a change in condition, and annually. The facility's document titled PASARR, dated April 2022, indicated that the nursing facility is responsible for ensuring that PAS and ARR processes are completed appropriately and timely. No additional documentation or information was provided by the Nursing Home Administrator and Director of Nursing during the exit conference.
Deficiencies in Wound Care and Medication Management
Penalty
Summary
The facility failed to provide wound care according to treatment orders for a resident with skin conditions. The resident, who had a diagnosis of Parkinson's Disease and a history of falls, was observed with outdated bandages on his left forearm and right hand. An LPN admitted to not changing the bandages as required and inaccurately documenting that the wound care was performed. The Unit Manager and Director of Nursing confirmed that the wound care was not provided as per the physician's orders and that documentation should reflect actual care provided. The facility also failed to follow up on pharmacist recommendations in a timely manner for a resident with multiple diagnoses, including moderate protein-calorie malnutrition, type 2 diabetes, and heart failure. The pharmacist had recommended changes to the resident's medication regimen, which were agreed upon by the physician, but these changes were not implemented promptly. The Director of Nursing acknowledged that the determination of the pharmacist's recommendations should be completed within seven days, but this was not adhered to. Additionally, the facility did not consistently hold antihypertensive medication per physician's order and failed to check blood pressure prior to administration for two residents. One resident, who had severe cognitive impairment and was diagnosed with persistent atrial fibrillation and hypotension, was administered Midodrine without checking blood pressure, contrary to the physician's order to hold the medication if systolic blood pressure was above 130. The Director of Nursing confirmed that blood pressure should have been taken prior to each administration, but this was not done on several occasions.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to consistently implement interventions to prevent the development of pressure wounds for a resident, identified as R19, who was at high risk for pressure ulcer development. Observations revealed that R19's left heel was frequently resting directly on the sheeted mattress, despite the care plan indicating the need for heel lift boots to be worn while in bed. Interviews with staff, including LPNs and CNAs, indicated inconsistencies in the application of these interventions, with some staff noting that R19 did not like to wear the boots, while others stated that R19 was compliant with wearing them. There was no documentation of attempts to apply the boots or any refusals by R19. R19 had a history of severe cognitive impairment, dysphagia following cerebral infarction, vascular dementia, and severe protein-calorie malnutrition, which increased the risk of pressure ulcer development. The resident had a previous pressure sore on the left heel and was identified as having a Stage 3 pressure ulcer on the left lateral calf. The care plans included interventions such as elevating heels and using heel lift boots, but these were not consistently followed, as evidenced by the observations and interviews conducted during the survey. The facility's policy on skin and wound care, which included the use of the Braden Scale to assess pressure ulcer risk, was not adequately implemented for R19. The Director of Nursing acknowledged that R19's foot should not be lying directly on the bed due to vascular concerns, yet there was no documentation of interventions related to refusals to elevate feet or wear protective boots. The lack of consistent implementation of the care plan and failure to document refusals contributed to the deficiency identified by the surveyors.
Failure to Monitor Nutritional Status of High-Risk Residents
Penalty
Summary
The facility failed to obtain weekly weights and perform timely nutrition reviews for two residents who were at high nutritional risk. Resident #1, who had diagnoses including moderate protein-calorie malnutrition, type 2 diabetes mellitus, and heart failure, was identified as having fluctuating weight due to various health conditions. Despite a recommendation for weekly weight monitoring starting from 5/28/24, only one weight was recorded between 5/28/24 and 6/25/24. The resident's care plan also noted inadequate oral intake and a dislike of food, with interventions including weekly weights, which were not consistently followed. Resident #19, with severe cognitive impairment and reliant on enteral feeding due to dysphagia, was also at high nutritional risk. The last nutrition assessment for this resident was completed on 3/27/24, and there was no monthly follow-up as required for high-risk residents. The Registered Dietitian acknowledged the oversight in both cases, noting that the recommendations for weekly weights and monthly follow-ups were not adhered to. The Director of Nursing confirmed that the Registered Dietitian was expected to see patients timely and that weight measurements should have been conducted for Resident #1.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to administer medications accurately, resulting in a medication error rate of 7.41%. During a medication pass, an LPN administered medications to a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dementia, and asthma. The LPN gave two sprays of Flonase in each nostril instead of the prescribed one spray per nostril. Additionally, the resident requested a PRN breathing treatment, which the LPN provided, despite the absence of a PRN order for Albuterol. Upon review, it was confirmed that the resident did not have a PRN order for Albuterol, and the LPN acknowledged the error in administering the incorrect dose of Flonase. The Director of Nursing emphasized the importance of checking the Medication Administration Record to ensure the correct dose and presence of an order before administering medications. The facility's Medication Administration policy outlines the necessity of adhering to the rights of medication administration, including the right dose and right medication.
Failure to Provide Vaccination and Education
Penalty
Summary
The facility failed to ensure that two residents, identified as R37 and R60, were provided with influenza and/or pneumococcal vaccinations and the necessary education regarding these immunizations. During an interview with the Infection Preventionist, it was revealed that there was no documentation in the Electronic Health Records (EHR) for these residents indicating that the vaccines were offered or contraindicated. R37, who was admitted with diagnoses of Multiple Sclerosis and Parkinson's Disease, and R60, admitted with a diagnosis of Heart Failure, both lacked documentation of being offered the vaccines or any refusal thereof. The Director of Nursing confirmed that both residents and/or their guardians should have been educated and offered the vaccines. The facility's policy, revised on March 1, 2022, states that residents should be offered the influenza vaccine annually between October 1 and March 31, and pneumococcal vaccines as recommended by the CDC upon admission, with documentation reflecting the education provided and details regarding the immunizations.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was provided with COVID-19 vaccination and education, which resulted in a potential risk for the development and spread of COVID-19 among vulnerable residents. The deficiency was identified during an interview and record review conducted on 6/28/2024, where the Infection Preventionist (IP) reported that R37 did not have documentation of a current COVID-19 immunization or refusal. R37 was admitted with diagnoses of Multiple Sclerosis and Parkinson's Disease, yet there was no documentation indicating that the COVID-19 vaccine was offered or contraindicated. On 7/2/2024, the Director of Nursing (DON) confirmed that R37 should have been educated and offered the COVID-19 vaccine. The facility's policy, revised on 3/1/22, states that residents will be offered the COVID-19 vaccine, and documentation should reflect the education provided and details regarding whether or not the resident received the vaccine.
Deficiency in Room Level Compliance
Penalty
Summary
The facility failed to provide resident bedrooms that are at or above ground level in six of the 70 rooms, specifically rooms 101, 103, 105, 107, 109, and 111. During an environmental tour, it was observed that these rooms were below grade level, with windows that had a visual line of sight looking up and out, indicating that the ground leveled out at the base of the windows. An interview with the Housekeeping and Laundry Director revealed that these rooms had been in this condition for several years but are no longer in use. No water damage was observed in these rooms during the survey.
Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to provide adequate supervision during the delivery of care for a resident, resulting in the resident rolling out of bed and sustaining a skin tear. The resident, who had a history of stroke with left-sided weakness, required a two-person assist for bed mobility. However, during a bed bath, only one CNA was present, and the resident rolled out of bed when attempting to assist the CNA by pulling on the headboard. This incident led to the resident falling onto the floor and sustaining a skin tear on the left knee, although x-rays showed no fractures or other injuries. The CNA involved in the incident admitted to being unaware that the resident required a two-person assist, as they did not usually work that set. The facility's records, including the Minimum Data Set (MDS) and Kardex, clearly indicated the need for two-person assistance for bed mobility. The Nurse Manager and other staff confirmed that the resident was assessed to need two-person assistance and acknowledged that the CNA did not follow the care plan, leading to the fall and injury.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R102) who was admitted with diagnoses including Dementia and Hemiplegia affecting the left non-dominant side. The resident, who had no cognitive impairment as per a recent MDS assessment, reported having a wet brief and not being changed since midnight. Observations confirmed that the resident's brief was heavily soiled, and the bed pad and draw sheet were wet. Certified Nursing Assistant (CNA) A did not check and change the resident until 9:33 a.m., despite the resident's report of needing assistance and the facility's policy requiring checks approximately every two hours or as needed. Interviews with CNA A and the Assistant Director of Nursing (ADON) revealed that staff were expected to check residents for incontinence at the beginning of their shift and every few hours thereafter. However, CNA A admitted to not checking the resident until later in the morning. The facility's Peri Care policy, which mandates incontinent care assistance based on resident request and regular checks, was not followed, leading to the resident experiencing prolonged discomfort and potential skin issues due to the wet and soiled brief.
Failure to Implement Comprehensive Care Plan for Vision and UTI
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with vision impairment and chronic urinary tract infections. The resident, who had a history of falls and was recently treated for a urinary tract infection, reported ongoing issues with a burning sensation in the bladder and had new glasses that improved vision. Despite these issues, the care plan did not address the resident's vision deficit or recurrent urinary tract infections. The resident had fallen nine times since November, and the care plan lacked entries for these concerns. Interviews with the Director of Nursing, Nursing Home Administrator, and MDS Coordinator confirmed the absence of care plan entries for the resident's vision and urinary tract issues. A vision exam form in the resident's chart indicated severe, constant blurry vision in both eyes, but this did not trigger a care plan entry. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Obtain Timely Physician's Order for Ileostomy Care
Penalty
Summary
The facility failed to obtain a physician's order in a timely manner for a resident (R201) with an ileostomy, resulting in unmet care needs. R201 was admitted with diagnoses including hemiplegia, hemiparesis, and ileostomy status. Despite the resident's severe cognitive impairment and need for specific ostomy care, the facility did not have a care plan for the ileostomy at the time of admission. The physician's orders for ostomy care were not initiated until 2/29/2024, leaving a gap from the admission date on 2/15/2024 without proper documentation and monitoring of the ileostomy. The Director of Nursing (DON) confirmed that the admitting nurse should have initiated a care plan for the ileostomy care and monitoring. The lack of a care plan and delayed physician's orders meant that the resident's ileostomy went without necessary care and monitoring for an extended period. This included the absence of documentation and output monitoring, which are critical for assessing the condition of the stoma and ensuring the ileostomy bag is secure. The DON acknowledged the importance of these measures to prevent complications such as redness, bloody content, and ensuring the bag's secure placement.
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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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