Optalis Health And Rehabilitation Of Canton
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Michigan.
- Location
- 7025 Lilley Road, Canton, Michigan 48187
- CMS Provider Number
- 235618
- Inspections on file
- 35
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 36 (1 serious)
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Canton during CMS and state inspections, most recent first.
A resident with significant communication impairment and a history of stroke was reported by family to have an unexplained lip issue and to be upset about it. The social worker documented the family’s concern and a subsequent visit where the resident pointed to their mouth and indicated a desire to see someone, but no skin or oral assessment was documented in the EHR. An LPN stated they observed a small, dried crack on the resident’s bottom lip but did not document the finding or conduct any interviews. The DON later produced a paper investigation file concluding the resident bit down on a toothbrush during oral care, based solely on an unsigned statement from a single agency CNA, with no additional interviews, assessments, or documentation. These actions did not follow the facility’s abuse policy requiring a timely, thorough, and well-documented investigation of alleged injuries of unknown source.
A resident with a history of recurrent UTIs and abdominal pain had multiple NP orders for a UA with C&S, but staff failed to obtain the specimen in a timely manner. After an initial refusal of straight catheterization documented by an LPN, there was no documentation of further attempts to collect urine despite care plan information showing the resident was usually continent and able to use the toilet with assistance. The NP re-ordered the UA twice before an RN ultimately obtained a clean-catch urine sample using a collection hat in the toilet, highlighting a prolonged delay in following the ordered diagnostic testing.
A resident with intact cognition who required assistance with most ADLs reported that a CNA knew the resident was wet but delayed providing incontinence care for about an hour, then yelled at the resident for several minutes while changing them after the resident requested a clean gown and sheet. The CNA stated they did not have time to obtain the requested items and would return later, leaving the resident feeling degraded, humiliated, anxious, and uncomfortable. The CNA did not return with the clean linens for approximately two more hours, during which the resident remained in urine. During interviews, the resident became tearful when recounting the incident, and facility leadership later confirmed that the conduct constituted verbal abuse and neglect under the facility’s abuse policy.
A resident admitted with frostbitten feet and intact cognition was documented on admission as having frostbite to both feet, but staff did not obtain physician orders or document assessment, monitoring, or treatment of the feet or dressings. A family member reported that the resident arrived with bandages on both feet, reminded staff that the bandages had not been changed, and later found the same original hospital bandages still in place with a foul odor before calling emergency services for hospital transfer. Review of records showed no related orders, no detailed nursing assessments of the feet, and no skin care plan interventions for the foot wounds, despite facility policy requiring evaluation and documentation of skin alterations by a licensed nurse.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and a history of agitation was found sleeping with her head on a nurses' station desktop, unsupervised and not positioned with dignity. The RN responsible acknowledged this was not appropriate, and the DON confirmed it did not meet facility standards for resident dignity, despite care plan interventions for supervision and visibility.
A resident was found sleeping in a wheelchair with her head on the nurse's station desk while a Nurse Practitioner was present but not attending to her, and no other staff were in the area. This situation failed to uphold the resident's dignity as required by federal regulations.
A resident with a PEG tube and a history of dysphagia was observed self-administering oral medications without staff supervision, contrary to physician orders specifying administration via PEG tube. The LPN confirmed that the resident had not been assessed for self-administration, and the facility's policy requiring direct observation during medication pass was not followed.
A resident with a PEG tube and a history of dysphagia and aspiration was observed self-administering whole pills orally without staff supervision, despite physician orders specifying medication administration via PEG tube. Staff interviews confirmed the resident was at high risk for aspiration, and there was no assessment or care plan allowing self-administration of medications by mouth.
A resident with a PEG tube and history of dysphagia was observed self-administering oral medications without staff supervision, despite the MAR indicating medications were given via PEG tube. An LPN confirmed the medications were given orally and not as documented, and there was no assessment, care plan, or order for self-administration in the resident's record.
The facility failed to provide adequate shower linens, resulting in an unclean environment. Observations showed insufficient linens, with staff using alternatives like pillowcases. Two residents, one with pressure ulcers and another post-joint replacement, were directly affected, having to reuse or purchase personal supplies. The facility's linen guidelines were not followed, and the NHA was unaware of the shortage.
A resident's wireless earbuds were misappropriated by a facility housekeeper. The resident, in short-term rehab care, used an app to locate the missing earbuds on the housekeeper's cart. An investigation, including security footage review, confirmed the misappropriation, leading to the housekeeper's termination.
The facility failed to provide proper transfer assistance for two residents, resulting in falls. One resident with ovarian cancer fell during a transfer due to inadequate use of a mechanical lift, while another resident with brain cancer fell when staff attempted to walk them to the bathroom instead of using a mechanical lift as required by their care plan.
A resident with ovarian cancer and severe malnutrition did not receive the correct dosage of TPN due to a failure in documentation and administration processes. The resident was supposed to receive two bags of TPN daily but was only receiving one, and missed an entire dose on one occasion. The issue was identified by the resident and a family member, and confirmed by the RD and DON, who noted that the TPN order was not documented in the electronic health record or MAR.
A facility failed to change a resident's PICC line tubing daily as ordered by the physician, increasing the risk of infection. The resident, with ovarian cancer and severe malnutrition, required daily tubing changes for safety monitoring. However, documentation showed that the tubing was not changed on two consecutive days, and the DON confirmed the protocol was not followed.
A facility failed to inform a cognitively impaired resident's representative of a change in condition, missing an opportunity for the representative to participate in medical decisions. The resident had severe cognitive impairment and was dependent on all ADLs. Despite worsening of a pressure ulcer and abnormal lab results, the family was not notified. Interviews with staff confirmed the oversight, which violated the facility's policy on Change in Condition Notification.
A resident with severe cognitive impairment and dependency on all ADLs was not identified as having dentures, leading to inadequate oral care. The facility's admission evaluation incorrectly noted the absence of dentures, and no interventions were in place for denture care. Hospital staff later found the resident's dentures packed with dried food and mold, and the resident's mouth was extremely dry and bleeding. Facility staff were unaware of the resident's dentures, and the facility's oral care policy was not followed.
A resident with a history of urinary retention and multiple fractures experienced a delay in the insertion of a Foley catheter, as ordered by a physician. The order was confirmed by an RN nine hours after being created and executed by an LPN 17 hours later, causing the resident discomfort until the catheter was placed. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
The facility failed to provide adequate nursing staff to meet the needs of 72 residents, with only two nurse aides per floor for 32 residents each. Despite the Facility Assessment indicating a need for more aides, staffing was based on census rather than resident acuity. Interviews with staff and residents revealed the impact of insufficient staffing, such as delays in assistance and missed showers.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. From June 1st to June 3rd, the DON provided coverage due to RN call-offs, which was inappropriate since the DON cannot fulfill this role. This deficiency potentially affected all 72 residents by risking inadequate care coordination.
The facility failed to provide accurate and complete information on Advance Medical Directives (AMD) for eight residents, resulting in their medical care preferences not being followed. Residents or their legal guardians were not informed about formulating an AMD, as required by the facility's policy. This deficiency was identified through interviews and record reviews, revealing a lack of documentation and communication regarding AMDs for residents with varying cognitive abilities.
A resident experienced embarrassment and humiliation after being taken to physical therapy in a wet brief, despite informing the PTA. The resident remained in the wet brief for 45 minutes, and upon returning to his room, found the bed unchanged. Staff interviews revealed a lack of timely response and awareness of the incident, which was reported weeks later.
A resident with multiple health conditions did not receive scheduled showers for over two weeks, despite being cognitively intact and requiring assistance with hygiene. The resident's wife intervened after staff failed to address the issue, and documentation was found to be disorganized and incomplete. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, and the DON acknowledged the deficiency.
The facility failed to communicate effectively with hospice staff, resulting in a resident not receiving a needed Alternating Pressure Relief Mattress. Additionally, the facility inaccurately documented weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The hospice staff had difficulty accessing the resident's EHR, and the facility's documentation was incomplete, contributing to these deficiencies.
A resident with cataracts experienced delayed treatment due to the facility's failure to schedule an ophthalmologist appointment, despite multiple requests and a documented order. The resident, who enjoys reading and using an iPad, expressed difficulty seeing. The social worker was unaware of the appointment status, and the nurse practitioner confirmed the appointment should have been made. Facility policies require the social worker to assist in scheduling appointments, which was not followed.
A facility failed to label a tube feeding container and hydration flush bag for a resident with impaired cognition, risking incorrect product and dosage administration. The resident's orders included Glucerna 1.5 and a water flush, but the facility lacked a policy on proper labeling, as confirmed by interviews with the UM and DON.
A facility failed to address a pharmacist's recommendations for a resident's medication regimen, potentially leading to unnecessary medication continuation. The resident, with multiple diagnoses, was on Buspirone and Escitalopram, and the pharmacist recommended a dose reduction of Buspirone. However, these recommendations were not addressed for three months due to documentation errors and lack of communication.
The facility failed to monitor blood glucose levels per physician orders for a resident with Type 2 Diabetes and Sepsis, resulting in the resident being sent to the hospital with elevated blood sugar levels and diabetic ketoacidosis (DKA). Interviews with staff confirmed that the monitoring should have occurred, but it was not documented.
The facility failed to report an allegation of abuse for a resident with moderate cognitive impairment. The resident alleged that a heavy woman tried to wake her up, describing the experience as feeling like 'a bull laid on me.' Despite the facility's policy requiring immediate reporting of abuse allegations, the Nursing Home Administrator did not report the incident to the State Agency, as she did not find the allegation substantiated within the 2-hour investigation window.
The facility failed to investigate an allegation of abuse for a resident with moderate cognitive impairment. The resident alleged that a heavy woman tried to wake her up, describing the experience as feeling like 'a bull laid on me.' The investigation lacked a documented interview of the LPN involved, and the Nursing Home Administrator confirmed that only a verbal interview was conducted and not documented.
Failure to Thoroughly Investigate Alleged Lip Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of an injury of unknown origin to a resident’s lip. The resident had a history of stroke with right-sided hemiparesis and aphasia and was documented on the MDS with a BIMS score of 0/15, indicating they were rarely understood or unable to complete the mental status interview. A family member contacted the social worker to report concerns about the resident’s care over a weekend and specifically that the resident had something on their lip and was upset about it. During this call, the Nursing Home Administrator, who is also the abuse coordinator, became aware of the concern. Subsequently, the social worker documented a wellness visit with the resident, noting that when asked about how they were doing following the incident, the resident repeatedly pointed to their mouth and nodded yes that they wanted to see someone regarding the incident. However, there was no documented skin assessment or oral assessment in the electronic health record related to the lip injury, and no additional progress notes describing the condition of the resident’s mouth, lips, or oral cavity. The social worker stated that they did not assess the inside of the resident’s mouth, indicating that such an assessment would be for nursing to perform. The nurse unit manager LPN reported that they had looked at the resident’s mouth and observed a small, dried crack on the bottom lip that appeared chapped, but confirmed there was no progress note or documentation of this assessment and that no interviews or investigation were conducted by them. The DON later stated that an investigation had been completed and kept in a paper file, concluding that the resident bit down on a toothbrush during oral care, causing a small crack or split on the bottom lip that looked like chapped lips rather than an injury. The DON reported interviewing only one CNA, an agency staff member, whose unsigned witness statement described the lip slit occurring during oral care; no other staff or resident interviews, additional assessments, or documentation were completed. This limited and poorly documented response did not meet the facility’s own abuse policy requirements for a timely, thorough, and objective investigation of alleged injuries of unknown source, including comprehensive interviews, observations, record review, and complete documentation.
Failure to Obtain Ordered Urinalysis in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for a urinalysis (UA) with culture and sensitivity (C&S) for a resident with a history of recurrent UTIs and complaints of abdominal pain. The resident was admitted with multiple diagnoses including a history of UTI. On 2/5/26, the NP ordered a UA with C&S. On 2/6/26, an LPN documented that the resident refused straight catheterization and that a urine sample could not be obtained. There was no documentation of any further attempts to obtain the ordered UA and C&S at that time, despite the resident’s care plan indicating they were usually continent of urine and able to use the toilet with 1–2 person assist, and a care plan for dehydration related to UTI that included obtaining labs as ordered and reporting abnormal results. Nineteen days later, on 2/24/26, the NP re-ordered the UA and C&S, but there was still no documentation that a urine sample was collected. On 3/1/26, the NP again re-ordered the UA and C&S, and on that same day an RN documented that a UA was collected and sent to the lab using a clean-catch method with a collection hat placed in the toilet. Interviews with nursing staff confirmed that attempts had been made to obtain urine via straight catheterization, that the resident declined this method, and that there were progress notes indicating the resident could urinate in a toilet with assistance. The unit manager could not explain why a clean-catch method was not used earlier, and the Nursing Home Administrator acknowledged that the urine sample was not collected in a timely manner.
Failure to Protect Resident From Verbal Abuse and Neglect During Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse and neglect by a CNA. The cognitively intact resident, who had a BIMS score of 15/15 and required assistance with most ADLs, reported that on the day of the incident the CNA entered the room, placed a brief in the room, and was aware the resident was wet and needed assistance but did not provide care for approximately one hour. When the CNA returned, the resident requested a clean gown and flat sheet due to being wet with urine. The resident stated the CNA began yelling, saying the resident should have requested those items earlier, that she did not have time to obtain them, and that she would change the resident quickly and return later with the requested items. The resident reported the CNA yelled for about five minutes while providing care, which caused the resident to cry and feel degraded, humiliated, anxious, and uncomfortable. The resident further reported that the CNA did not return with the requested clean gown and flat sheet for approximately two hours, during which time the resident remained anxious and uncomfortable while sitting in urine. During follow-up interviews, the resident became tearful when recounting the incident and expressed sadness about being treated in that manner and wishing to be able to care for herself. Record review confirmed the resident’s need for assistance with daily hygiene and grooming. Facility leadership, including the DON and Nursing Home Administrator, reported that an investigation was conducted and that abuse was substantiated, and both acknowledged that yelling at residents constitutes verbal abuse and that making the resident wait so long for needed incontinence care and linens constituted neglect. The facility’s abuse policy states residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.
Failure to Assess and Document Care for Resident With Frostbitten Feet
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals by not adequately assessing, monitoring, or documenting the condition of a resident’s frost-bitten feet. The resident was admitted with diagnoses including pain in both feet and frostbite of the feet, and the admission evaluation documented frostbite to both feet under the integumentary section. The resident’s BIMS score indicated intact cognition. A family member reported that the resident was admitted with bandages on both feet and that during a visit the day after admission, nursing staff were reminded that the bandages had not been changed. On the following morning, the family member again found both feet still wrapped in the original hospital bandages, which had a bad stench, and after staff did not respond in a timely manner, emergency services were called and the resident was transported to the hospital. Record review showed there were no physician orders to assess, monitor, or provide care for the resident’s bilateral feet, and no documentation in progress notes from admission through the date of transfer describing the feet, assessing them, or monitoring them. Medication and treatment administration records contained no related physician orders, and skilled nursing notes either omitted any assessment of the feet or only noted that dressings were present, without further description. The resident’s skin care plan contained no interventions for monitoring, assessment, or treatment of the feet. The DON stated that the resident had no dressings applied at admission, that the feet should have been assessed and monitored regardless of any bandage, and later acknowledged that nursing staff should have thoroughly examined and documented the bandages and notified the physician so that treatment orders could be obtained. Facility policy required that skin alterations be evaluated and documented by a licensed nurse using the admission or readmission evaluation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Resident Dignity Not Maintained During Supervision Lapse
Penalty
Summary
A resident with severe cognitive impairment, altered mental status, and a history of restlessness and agitation was observed sleeping at the nurses' station with her head resting directly on the desktop. The registered nurse responsible for her care acknowledged that this positioning was not optimal and did not maintain the resident's dignity, stating that the resident should have been returned to her room to sleep in her bed. The nurse was not in a position to directly supervise the resident at the time she was observed, and another nurse practitioner present stated she was not responsible for the resident but had been helping to keep her calm. The resident's care plan included interventions such as encouraging her to be in common areas when awake, increasing the frequency of checks, and ensuring she was up in a wheelchair in visible fields when rambling. Despite these interventions, the resident was left unsupervised and allowed to sleep in a public area in a manner that did not promote dignity or respect, as required by facility policy. The Director of Nursing confirmed that this did not meet the facility's standards for maintaining resident dignity and that alternative arrangements were available for such situations.
Resident Dignity Not Maintained at Nurse's Station
Penalty
Summary
A deficiency was identified when a resident was observed sleeping at the Beck nurse's station, seated in a wheelchair with her head resting directly on the desk. At the time of observation, a Nurse Practitioner was present in the nurse's station but was seated in a different area, facing away from the resident and actively typing on a computer. No other staff members were present in the area during this time. The incident was noted during a review focused on respect, dignity, and the right of residents to retain and use personal possessions, as outlined in §483.10(e). The facility failed to maintain the dignity of the resident by allowing her to sleep in a public and potentially undignified manner at the nurse's station without staff engagement or intervention.
Failure to Supervise Medication Administration and Follow Physician Orders
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed self-administering oral medications without staff supervision. The resident, who has a PEG tube, was seen walking out of his room holding a medication cup with approximately four pills, dropping one on the floor, picking it up, and returning it to the cup before ingesting the remaining pills. The resident was not supervised during this process, despite facility policy requiring direct observation during medication administration. The resident's electronic health record did not contain an assessment for self-administration of medications, a care plan for self-administration, or a physician's order permitting self-administration. Further review of the physician's orders indicated that all prescribed medications were to be administered via the PEG tube, not orally. The LPN involved acknowledged that supervision should have occurred and that the resident had not been formally assessed for self-administration. The DON confirmed that the resident was not assessed for self-medication and should have been supervised. Facility policy also specifies that medications must remain under the direct observation of the person administering them during medication pass, which was not followed in this instance.
Failure to Administer Medications via PEG Tube and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with a PEG tube and a history of dysphagia, cerebral ischemia, and recurrent aspiration was observed self-administering whole pills orally without staff supervision. The resident was seen walking out of his room holding a medication cup with several whole pills, dropping one on the floor, picking it up, and then returning to his room to swallow the pills. The resident's medical record indicated that all prescribed medications were ordered to be administered via PEG tube, and there was no assessment, care plan, or physician order permitting self-administration of medications by mouth. Interviews with staff, including an LPN and the SLP, confirmed that the resident was at high risk for aspiration and that medications should have been given via PEG tube as ordered. The SLP noted that the resident coughed when attempting to swallow pills and was at risk for silent aspiration. The facility's policy required verification of physician orders and monitoring for aspiration during tube feeding, but these procedures were not followed in this instance, resulting in the resident receiving medications by an incorrect route and without adequate supervision.
Failure to Accurately Document and Supervise Medication Administration
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed independently taking oral medications from a medication cup without staff supervision. The resident, who had a PEG tube in place, dropped a pill on the floor, picked it up, and returned it to the cup before ingesting the remaining pills. The resident stated he was taking his pills, and there was no staff present to supervise the administration. Interview with an LPN revealed that the resident was given several medications in pill form to take orally, and the LPN acknowledged not supervising the resident during administration. Review of the resident's electronic health record showed no assessment, care plan, or order for self-administration of medications. Additionally, the Medication Administration Record (MAR) inaccurately documented that the medications were administered via PEG tube, contrary to the actual oral administration observed. The Director of Nursing confirmed the inaccuracy in the MAR and stated that documentation should reflect the actual treatment provided.
Linen Shortage Leads to Unclean Environment
Penalty
Summary
The facility failed to provide adequate shower linens, such as towels and washcloths, for its residents, resulting in an unclean and uncomfortable environment. Observations and interviews revealed that the facility had insufficient linens, with some units having zero towels and washcloths available. Staff members reported having to use alternative items like pillowcases and cut-up gowns to clean residents due to the shortage. The Housekeeping Director acknowledged the lack of linens, attributing it to staff shortages and ongoing laundry processes, while the Nursing Home Administrator (NHA) was unaware of the linen issues and claimed that staff did not communicate their needs effectively. Two residents, identified as R112 and R113, were directly affected by the linen shortage. R112, who had pressure ulcers and other medical conditions, reported purchasing personal supplies due to the facility's inadequacy. R113, who had undergone joint replacement and experienced difficulty walking, stated they were given only one washcloth, which they had to reuse for several days. Both residents' care plans indicated the need for assistance with daily hygiene, which was compromised by the lack of available linens. The facility's Linen Supply Guidelines required regular replenishment of linens, but these guidelines were not followed, leading to the deficiency. The NHA could not explain the shortage despite the inventory process and suggested that CNAs were discarding and cutting up linens. The facility's policy on maintaining a homelike environment emphasized the importance of clean and sanitary conditions, which were not met due to the linen shortage.
Misappropriation of Resident's Property by Facility Employee
Penalty
Summary
The facility failed to protect a resident's personal property from theft by an employee, resulting in the misappropriation of the resident's wireless earbuds. The incident involved a resident who was in the facility for short-term rehabilitation care and was alert and oriented. The resident reported to the Director of Nursing (DON) that their Apple AirPods were missing after they left their room for activities. Upon returning, the resident used an app to locate the earbuds, which were found on a housekeeper's cleaning cart. The resident informed the housekeeper, who then returned the earbuds and was instructed to report the incident to a supervisor. The facility conducted an investigation, which included reviewing security camera footage. The footage showed the housekeeper entering the resident's room and placing something at the bottom of the cleaning cart. The housekeeper, who had been employed at the facility for a short period, was interviewed and subsequently suspended pending the investigation. The investigation substantiated the allegation of misappropriation, leading to the termination of the housekeeper. The facility's policy on abuse, updated in May 2023, states that residents have the right to be free from misappropriation of property.
Failure to Ensure Proper Transfer Assistance
Penalty
Summary
The facility failed to ensure proper transfer assistance for two residents, leading to accidents. Resident R102, who had diagnoses including ovarian cancer and severe protein-calorie malnutrition, experienced a fall during a transfer back to bed. The care plan for R102 required one-person assistance with a two-wheeled walker and gait belt. However, during the incident, R102's knees buckled, and she fell to the floor. The CNA and RN involved in the transfer did not use a mechanical lift, as required by the facility's policy, and instead manually lifted R102, which was not in accordance with the guidelines. Resident R103, diagnosed with brain cancer and a history of repeated falls, also experienced a fall due to inadequate assistance. R103's care plan required a full mechanical lift for transfers, but staff attempted to walk R103 to the bathroom, resulting in a fall. The DON confirmed that R103 should have been transferred with two-person assistance and a mechanical lift. The facility's policy on fall management was not followed, as the staff did not use the mechanical lift for either resident, leading to the deficiencies noted in the report.
Failure to Administer Correct TPN Dosage
Penalty
Summary
The facility failed to ensure the correct administration of Total Parenteral Nutrition (TPN) for a resident diagnosed with ovarian cancer and severe protein-calorie malnutrition. The resident, who had intact cognition, was supposed to receive two bags of TPN daily to meet her nutritional needs but was only receiving one bag per day and missed an entire dose on one occasion. This discrepancy was identified when the resident and a family member reported the issue, indicating that the TPN had not been administered correctly since a specific date. The Registered Dietitian (RD) and the Director of Nursing (DON) confirmed that the TPN order was not documented in the electronic health record or the Medication Administration Record (MAR). The DON revealed that the TPN administration was never transcribed onto the MAR, and the nursing staff failed to document the administration in the progress notes. Additionally, the facility staff were administering TPN bags containing lipids but not the clear TPN bags, resulting in the resident not receiving the prescribed amount of TPN.
Failure to Change PICC Line Tubing as Ordered
Penalty
Summary
The facility failed to consistently change the PICC line tubing according to the physician's order for a resident who was receiving parenteral nutrition, which increases the risk of infection. The resident, who was admitted with diagnoses including ovarian cancer and severe protein-calorie malnutrition, had a care plan indicating the need to change the IV tubing daily as per physician orders. However, a review of the resident's Treatment Administration Record revealed that the nursing staff did not document the tubing change on two consecutive days. The Director of Nursing confirmed that the protocol to change the tubing daily was not followed, and no additional documentation was provided to support that the tubing had been changed on those days.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to inform a cognitively impaired resident's representative of a change in condition, which resulted in a missed opportunity for the representative to participate in medical decisions. The resident, identified as R902, was admitted with diagnoses including dementia, pressure ulcers, and chronic kidney disease. The Minimum Data Set indicated severe cognitive impairment, and the resident was dependent on all Activities of Daily Living. A Skin and Wound Evaluation revealed that the resident's pressure ulcer had worsened to a Stage III, but documentation only noted that the patient was notified, not the resident's representative. Further review of the resident's records showed abnormal lab results and the initiation of IV fluids, yet there was no indication that the family was informed of these changes. Interviews with facility staff, including an LPN, an RN, and the Director of Nursing, confirmed that the resident's family should have been notified of the worsening condition and interventions. The facility's policy on Change in Condition Notification mandates that the resident's designated representative be informed of changes in medical or mental condition, which was not adhered to in this case.
Failure to Provide Adequate Oral Care for Resident with Dentures
Penalty
Summary
The facility failed to identify and provide adequate oral care for a resident with dentures, leading to a deficiency in the care of Activities of Daily Living (ADLs). The resident, who was admitted with diagnoses of dementia, pressure ulcers, and chronic kidney disease, was documented as being dependent on all ADLs and had severe cognitive impairment. Despite this, the facility's admission evaluation incorrectly noted that the resident did not have dentures, and there were no interventions in the care plan or Kardex to address denture care. The deficiency was discovered when a hospital employee observed the resident's dentures packed with dried food and mold. Hospital records indicated the resident's mouth was extremely dry, crusting, and bleeding, with mold appearing plaque buildup on the tongue, hard palate, and dentures. Interviews with facility staff revealed a lack of awareness regarding the resident's dentures, and the Director of Nursing stated that oral care should be provided on every shift for dependent residents. The facility's policy required oral care to be provided with morning and nighttime care and as needed, which was not adhered to in this case.
Delayed Execution of Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to follow a physician's order in a timely manner for a resident who required an indwelling urinary catheter. The resident, who had a history of urinary retention and other urological issues, was admitted with multiple fractures and required maximum assistance for mobility and toileting. On a specific date, the physician ordered the insertion of a Foley catheter due to the resident's inability to urinate independently. However, the order was not confirmed until approximately nine hours later by an RN, and the catheter was not inserted until about 17 hours after the order was created. Interviews with the nursing staff revealed that the order was passed from one shift to the next without being executed promptly. The LPN who eventually inserted the catheter noted that the resident expressed relief and had a significant urine output immediately after the procedure. Both the Medical Director and the Director of Nursing acknowledged that the standard practice is to carry out physician orders as soon as possible, and the delay in this case was unexplained. The facility's policy on physician orders emphasizes the importance of timely execution according to professional standards.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 72 residents, as observed during a survey. On the second floor, there were only two nurses and two nurse aides for 32 residents, while the first floor had two nurse aides for 32 residents. Interviews with staff, including a Unit Manager and an LPN, revealed that the usual staffing level was two nurse aides per floor, which was insufficient given the number of residents requiring two-person assistance for care needs. The Facility Assessment indicated that there should be one aide per eight residents, suggesting a need for more aides than were present. The Nursing Home Administrator and Director of Nursing confirmed that staffing was based on census rather than resident acuity, which led to inadequate staffing levels. The Director of Nursing acknowledged that the staffing was not sufficient according to acuity, and the Staffing Coordinator mentioned that more aides could be scheduled with approval. Interviews with CNAs and residents highlighted the impact of insufficient staffing, such as delays in assistance and missed showers. The facility's policy stated that staffing should be based on residents' care plans, but this was not reflected in practice.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN), excluding the Director of Nursing (DON), was on duty for eight consecutive hours a day, seven days a week. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage from June 1st through June 3rd. During this period, the DON had to step in to provide coverage due to call-offs, which was later identified as inappropriate since the DON cannot fulfill the role of an RN for this requirement. This lack of RN coverage had the potential to affect all 72 residents in the facility by possibly leading to inadequate coordination of emergent or routine care.
Failure to Provide Information on Advance Medical Directives
Penalty
Summary
The facility failed to provide accurate and complete information regarding Advance Medical Directives (AMD) for eight residents, resulting in their preferences for medical care not being followed. The report highlights that residents or their legal guardians were not fully informed about how to formulate an AMD, which is a legal document that allows individuals to specify their end-of-life care decisions in advance. This deficiency was identified through interviews and record reviews, revealing that the facility did not ensure residents or their legal representatives were aware of their rights to request, refuse, or discontinue treatment. For instance, one resident, who had a legal guardian, was marked as a full code in the Electronic Health Record (EHR) without any documentation indicating that information about AMDs was provided to either the resident or the guardian. Another resident, admitted with a Do Not Resuscitate (DNR) order from the hospital, was also marked as a full code without any documentation of discussions or information provided to the family regarding AMDs. The facility's policy required that information about AMDs be provided upon admission, but this was not consistently followed. Several residents with varying cognitive abilities, ranging from intact cognition to severe impairment, were found to have no documentation of AMD discussions or forms in their records. Interviews with social workers and reviews of clinical records confirmed the lack of documentation and communication regarding AMDs. The facility's policy stated that information should be provided to residents or their legal representatives, but this was not adequately implemented, leading to the deficiency.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R21, who was taken to physical therapy while wearing a wet brief. R21 reported the incident occurred on 6/21/24, when he informed the Physical Therapy Assistant (PTA) G of his condition, but no assistance was provided to change his brief. Instead, PTA G requested two nurse aides to change the linen on R21's bed before he returned to his room. However, upon returning to his room, R21 found the bed still had the same soiled linen, and he was left in a wet brief for approximately 45 minutes, leading to feelings of embarrassment and humiliation. R21 expressed his distress during an interview, stating that he felt disrespected and humiliated by the experience. Interviews with staff revealed discrepancies in the handling of the incident. PTA G denied being informed by R21 about the wet brief but confirmed requesting the linen change. CNA B confirmed that R21 was wet upon returning from therapy and required assistance. The Unit Manager (UMH) and Director of Nursing (DON) were unaware of the incident until weeks later, with a Concern Form being submitted to the Administrator and Physical Therapy Manager on 7/7/24. The facility's policy on dignity emphasizes care that promotes residents' well-being and self-esteem, which was not upheld in this instance.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident, identified as R21, who was admitted with multiple health conditions including heart failure, chronic kidney disease, and diabetes mellitus. Despite being cognitively intact with a BIMS score of 14 out of 15, R21 required assistance with transferring and hygiene. The resident reported not receiving a shower for two and a half weeks post-admission, leading to frustration and prompting his wife to intervene by giving him a shower herself. The resident had communicated his concerns to a corporate liaison, but the promised shower was not provided, and he continued to receive only bed baths. The investigation revealed that the Nurse Aide's Task Assignment for R21 did not include shower days, and the Shower Logbook was disorganized, with missing documentation for scheduled showers. Interviews with staff, including a CNA and the Unit Manager, indicated a lack of awareness and communication regarding the resident's unmet needs. The Director of Nursing acknowledged the incomplete and disorganized state of the shower documentation and confirmed that all residents should receive two showers a week, which was not adhered to in R21's case. The deficiency was further highlighted by the absence of a documented Concern Form related to the missed showers, despite the resident's wife reporting the issue to the Unit Manager.
Deficiencies in Hospice Communication and Weight Documentation
Penalty
Summary
The facility failed to effectively communicate and collaborate care with hospice staff for a resident receiving hospice services, resulting in the resident not receiving an Alternating Pressure Relief Mattress (APM). The resident's family member reported that the APM, intended for comfort care, had not been received despite being ordered by hospice a month prior. Observations confirmed that the resident was using a regular bariatric mattress, while the APM was found outside the resident's room. The facility's records showed a lack of documentation from hospice regarding the APM order, and a care conference did not include hospice participation or documentation of the APM order. The Director of Nursing (DON) revealed that hospice staff documented communications in a physical binder at the nurse's station, which was found to be blank. The Maintenance Director confirmed the APM was delivered but was the wrong size for the resident's bed, and there was no communication with hospice to rectify the issue. The hospice nurse was unaware of the mattress size issue and cited difficulties in communication due to lack of access to the resident's Electronic Health Record (EHR). Additionally, the facility failed to accurately obtain and document weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The resident's records showed an implausible weight loss of 127.4 pounds in one month, which was not supported by the resident's condition or dietary intake. Interviews with the resident, Registered Dietician, and Physician confirmed the weight loss was not possible and attributed the error to inaccurate weight measurements. Another resident's weight was also inaccurately recorded due to improper positioning during weighing, which was corrected upon re-evaluation.
Failure to Schedule Ophthalmologist Appointment for Resident
Penalty
Summary
The facility failed to schedule an ophthalmologist appointment for a resident, identified as R12, who was reviewed for vision services. This resulted in a delay in treatment for R12's cataracts. On July 9, 2024, R12 was observed in bed with several reading materials and an iPad, expressing difficulty in seeing due to cataracts and stating that multiple requests for an eye doctor appointment had not been fulfilled. R12's Electronic Health Record indicated a history of stroke and chronic obstructive pulmonary disease, with intact cognition as per the Minimum Data Set. A progress note from June 5, 2024, documented R12's complaint about worsening cataracts, and an order for an ophthalmology appointment was made on June 9, 2024, with the ophthalmologist's contact information provided. Despite these steps, there was no documentation of an appointment being made. On July 10, 2024, the social worker, SW K, was unaware of any appointment being scheduled and acknowledged the lack of follow-up after reviewing R12's records. Nurse Practitioner Z confirmed that the appointment should have been made, as the necessary information was included in the order. The facility's policy on Hearing and Vision Services and Consultations outlines the responsibility of the social worker to assist in making appointments and arranging transportation, which was not adhered to in this case.
Failure to Label Tube Feeding and Hydration Containers
Penalty
Summary
The facility failed to properly label a tube feeding container and a hydration flush bag for a resident, leading to the potential for administering the incorrect product and dosage. During an observation, it was noted that a bottle of Glucerna, a liquid nutrition formula, and a hydration bag were not labeled with essential information such as the date started, the resident's name, or the physician's order for infusion. This oversight was identified for one resident who was under review for nutrition. The resident involved had a pertinent diagnosis of gastrostomy status and impaired cognition, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The resident's physician orders specified the use of Glucerna 1.5 at a rate of 70 ml per hour and a flush order of 50 cc of water every hour via auto flush. Interviews with the Unit Manager and Director of Nursing confirmed that the containers should have been labeled before administration to ensure the correct resident received the proper dosage. However, the facility was unable to provide a policy or procedure guideline on labeling tube feeding and hydration containers by the end of the survey.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to respond timely to the pharmacist's Medication Regimen Review (MRR) recommendations for a resident, resulting in the potential continuation of unnecessary medications. The resident, who had diagnoses including major depressive disorder, heart failure, generalized anxiety disorder, and morbid obesity, was on medications such as Buspirone and Escitalopram. The pharmacist had recommended a gradual dose reduction of Buspirone, as per federal guidelines, to ensure the resident was on the lowest possible dose. However, these recommendations were not addressed for three consecutive months. The Director of Nursing (DON) confirmed that the pharmacy reports and recommendations for the resident were not documented in the electronic medical record (EMR) due to an error. The pharmacist explained that irregularities are documented in the EMR, but detailed reports are emailed to the facility. The facility's policy requires that findings and recommendations from the pharmacist be reported to the DON and attending physician, but this process was not followed, leading to the deficiency.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to obtain blood glucose levels per physician orders for a resident (R901) who had been admitted with diagnoses including Sepsis, Type 2 Diabetes, and Severe Sepsis with Septic Shock. Despite physician orders for blood sugar checks twice a day, there were no documented blood glucose levels in the resident's electronic health record. This oversight resulted in the resident being sent to the hospital with elevated blood sugar levels greater than 800 and evidence of diabetic ketoacidosis (DKA). The resident's care plan had included interventions for blood sugar testing, but these were not followed, leading to unmonitored blood glucose levels. Interviews with facility staff, including a Registered Nurse (RN), Unit Manager, and the Director of Nursing (DON), confirmed that blood glucose levels should have been monitored per physician orders, especially given the resident's use of Total Parenteral Nutrition (TPN). The DON acknowledged that the blood sugar monitoring order was not prompted for documentation, and the physician had to call to report the lack of monitoring. The facility's Parental Nutrition Administration policy also required routine monitoring of glucose levels for residents receiving TPN, which was not adhered to in this case.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse for one resident (R502) out of four residents reviewed for abuse. R502, who has a moderate cognitive impairment with a BIMS score of 8/15, alleged that a heavy woman tried to wake her up around 8:00 AM, describing the experience as feeling like 'a bull laid on me.' The investigation revealed that LPN A was providing care to R502, including taking her blood pressure and administering two breathing treatments. The timeline of events from the facility's cameras showed LPN A entering and exiting R502's room multiple times between 8:22 AM and 8:29 AM to provide care and medication. Despite the allegation, the Nursing Home Administrator (NHA) did not report the incident to the State Agency, as she did not find the allegation substantiated within the 2-hour investigation window. The facility's policy mandates that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes be reported immediately to the Administrator and the State Agency. Specifically, allegations involving abuse or serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. The NHA acknowledged that it is her expectation that all allegations of abuse should be reported within the required timeframe, yet this protocol was not followed in the case of R502.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse for one resident (R502) of four residents reviewed for abuse. R502, who has a moderate cognitive impairment with a BIMS score of 8/15 and medical diagnoses including encephalopathy and aphasia, alleged that a heavy woman tried to wake her up around 8:00 AM, describing the experience as feeling like 'a bull laid on me.' The facility's investigation report noted that LPN A was providing care, including taking R502's blood pressure and administering two breathing treatments. However, the investigation lacked a documented interview of LPN A's account of the incident. The Nursing Home Administrator confirmed that only a verbal interview was conducted and not documented.
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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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