Optalis Health And Rehabilitation Of Grand Rapids
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 1950 32nd Street Se, Grand Rapids, Michigan 49508
- CMS Provider Number
- 235458
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 31 (2 serious)
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Grand Rapids during CMS and state inspections, most recent first.
Two residents experienced worsening pressure injuries and infection due to the facility’s failure to transcribe, implement, and consistently provide ordered wound care. For one resident with cognitive impairment and incontinence, hospital discharge instructions for existing skin wounds and pressure prevention were not entered into facility orders or care plans, the sacral pressure ulcer was not promptly assessed or care-planned, wound provider orders for daily Manuka dressings and pressure-relief devices were entered incorrectly as every other day, and dressing changes were missed or left soiled for extended periods despite no documented refusals. The resident’s sacral ulcer progressed to a large, foul-smelling unstageable wound associated with sepsis. For another resident with a right heel pressure injury, wound provider notes over several months documented soiled, outdated, and incorrect dressings, deterioration of the unstageable heel ulcer, and concerns for cellulitis and infection, while treatment records showed multiple missed and undocumented dressing changes and incomplete antibiotic and topical treatment implementation. Staff interviews revealed lack of awareness of wound orders, reliance on night shift and agency nurses for dressings, and poor documentation of refusals, contributing to the cited deficiency in pressure ulcer care.
A resident with depression, generalized muscle weakness, impaired walking, and cognitive communication deficit, who was care planned as at risk for falls, was repeatedly observed in bed with the call light not visible and hanging behind the head of the bed near the floor, out of reach. Over multiple observations on consecutive days, staff did not ensure the call light was placed on or near the resident’s body as required. In interviews, CNAs and the ADON confirmed that call lights were supposed to be within residents’ physical reach and acknowledged that the observed placement behind the bed frame near the floor was not acceptable.
A resident with a right heel pressure injury had physician orders for specific wound care regimens and weekly skin evaluations, but records showed multiple missed and refused treatments without corresponding progress notes or PRN documentation, and several weekly skin checks were not completed. A NP twice found the heel dressing grossly soiled, unchanged for several days beyond ordered frequency, and once inconsistent with the ordered dressing type, and also noted that a prescribed topical antibiotic was not available. MARs showed the resident did not receive all ordered doses of oral antibiotics on two separate treatment courses. A TAR entry indicated an LPN had checked the heel dressing, but in interview the LPN stated she was unaware of any dressing despite having documented the check that morning. The ADON acknowledged finding unchanged dressings, missing or inconsistent documentation, and prior concerns from the wound care provider about dressings not being changed as ordered.
A resident with a full code status was found unresponsive and did not receive CPR from the assigned agency RN, who assumed hospice status meant DNR and did not verify the resident's documented wishes. Other staff were aware of the full code status, but no resuscitative efforts or emergency calls were made, resulting in the resident's death without basic life support.
Multiple residents were not protected from physical abuse, including one resident with dementia who was struck by another resident with a history of aggression, and another resident who was hit in the face by an agency LPN during an argument. The facility did not implement a behavior care plan for the aggressive resident prior to the incident and failed to thoroughly investigate the staff-to-resident abuse, collecting only one witness statement despite multiple available witnesses.
Two residents' narcotic medications were misappropriated due to failures in medication tracking, incomplete shift-to-shift controlled substance counts, and lack of proper documentation by nursing staff. Pharmacy and administration records did not account for all received doses, and required signatures and explanations for missing medications were absent, resulting in unaccounted controlled substances.
A resident reported being struck by an agency LPN during an argument related to insulin administration. Multiple witnesses, including a CNA and a family member, observed or heard the altercation, and a police report documented the incident. However, the facility's investigation was incomplete, as not all witnesses were interviewed and documentation was lacking, contrary to the facility's abuse policy.
A resident with complex cardiovascular conditions did not receive medications according to physician orders when an LPN administered Metoprolol and Midodrine together and outside the prescribed time frames. The medications, which have opposing effects on blood pressure and heart rate, were not to be given simultaneously, and one was administered late and not with a meal as ordered. This failure was confirmed by both the LPN and the unit manager.
A resident with chronic lymphedema, heart failure, and constipation did not receive consistent assessment, monitoring, or treatment as ordered. Nursing staff failed to provide timely bowel interventions, resulting in hospitalization for fecal impaction and hyperkalemia. Wound care was not performed per orders, with staff using briefs instead of prescribed dressings when supplies ran out, and there were missed applications of compression stockings and lymphedema boots without proper documentation. Medication administration records showed multiple missed treatments and lack of documentation for refusals.
A resident with multiple urinary and bladder conditions did not receive appropriate care for her Pure Wick external catheter, as staff failed to respond promptly to care requests, left the canister unemptied and uncleaned for extended periods, and lacked clear protocols or education on proper device maintenance. This resulted in inconsistent catheter replacement, inadequate cleaning, and insufficient monitoring, contrary to facility policy and manufacturer guidelines.
Surveyors found that current daily nurse staffing hours were not consistently posted in a prominent and accessible location. Outdated staffing information remained displayed for several days, and staff acknowledged that postings were not updated regularly as required.
A resident with multiple medical conditions on a vegetarian diet did not consistently receive her selected menu items, including missing meals and lack of suitable condiments, due to staff errors in ordering and meal preparation. Dietary staff acknowledged forgetting to order specific items and failing to provide planned meals, leading to resident dissatisfaction and concerns about limited vegetarian options.
A resident with severe dementia, poor safety awareness, and a history of falls was left unsupervised on a bedside commode despite requiring two-person assistance for all ADLs. Staff were not within arm's reach, and the resident fell, sustaining a fractured patella and head injury. Facility records and staff interviews confirmed the resident's need for direct supervision during toileting, which was not provided.
A resident with chronic pain and vascular dementia, who was fully dependent for care, sustained a nondisplaced distal radius fracture of unknown origin. Despite hospital records confirming the injury and facility policy requiring immediate reporting of such incidents, the facility did not report the injury to the state agency or address it in their internal investigation. Interviews revealed that key staff did not review or recognize the x-ray findings, resulting in a failure to follow required abuse and injury reporting procedures.
A resident who was bed bound and dependent on staff for all care was found to have a nondisplaced distal radius fracture during a hospital visit. Despite documentation of the injury in hospital records and the facility's policy requiring investigation of injuries of unknown source, the facility did not identify, investigate, or report the injury, and key staff were unaware of the documented fracture.
A resident at high risk for skin breakdown was not properly assessed or treated for a coccyx wound, despite staff observations and a care plan indicating the need for interventions. No treatment orders were obtained, and the wound worsened, as confirmed during a hospital visit. Facility leadership acknowledged that required wound care protocols were not followed.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident's legal guardian was not properly informed or accommodated to participate in the care planning process following the resident's readmission from a psychiatric facility. Despite policy requiring advance notice and participation, the guardian was unable to attend the care conference due to poor communication from facility staff, and the conference was inaccurately documented as attended.
A resident with significant mobility and coordination issues was unable to access their call light, which was found under the bed and out of reach. The resident, who depended on staff for assistance and was identified as a high fall risk, was observed attempting to stand unassisted and repeatedly calling for help. Facility policy requires call lights to be within reach, but this was not followed, resulting in the resident's inability to request staff assistance.
The facility did not ensure that a resident was protected from being separated from others, their room, or being confined to their room, resulting in a deficiency related to resident rights.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Staff did not consistently follow Enhanced Barrier Precautions for residents with wounds or indwelling devices, with multiple instances of care being provided without required gowns and gaps in staff knowledge of EBP policy. Additionally, the facility lacked an active water management plan, with stagnant water lines, infrequent flushing, and no routine testing for disinfectant levels, contrary to facility policy.
Surveyors found that medications, including insulin pens and eye drops, were not properly labeled with resident names or open dates, and expired medications were not removed from medication carts. Additionally, a medication cart containing narcotics was left unlocked and unattended in a hallway, contrary to facility policy requiring all medications to be securely stored.
Three residents with chronic medical conditions were not offered or did not have documentation of being offered COVID-19 vaccinations after 2022, despite facility policy requiring annual offers and documentation. The facility could not provide evidence that these eligible residents received education or offers for the updated vaccine.
The facility did not maintain a fully operational call light system, resulting in several residents experiencing malfunctioning call lights, long response times, and in some cases, call lights being out of reach. Staff and family interviews, as well as direct observations, confirmed ongoing issues with the system, including hallway indicators not activating and repeated maintenance requests that did not resolve the problems.
The facility did not ensure that agency staff received or completed mandatory training on infection prevention and Enhanced Barrier Precautions (EBP). Several agency nurses and a CNA reported not receiving EBP education or being asked to review relevant materials before starting work. One agency RN, unfamiliar with EBP, was preparing to perform wound care without proper protective equipment, highlighting the lack of effective training and verification processes.
A CNA publicly referred to three cognitively impaired residents as "lay backs" while they were seated in geri chairs near the nurses' station, in violation of the facility's dignity policy. The DON confirmed that such language is inappropriate and does not align with expectations for respectful communication with residents.
A resident with severe cognitive impairment and multiple diagnoses was administered several psychotropic medications without documented consent, as required by facility policy. Staff confirmed that no consents were on file prior to administration, and the care plan's intervention to provide education on medication risks and benefits was not documented as completed.
A resident with a history of muscle weakness and hemiplegia was found on the floor with injuries and was sent to the hospital after an unwitnessed fall. The LPN on duty contacted the physician and arranged the transfer but did not notify the resident's DPOA or emergency contact, as confirmed by interviews and documentation review. The facility's policy requires such notification, but it was not completed or documented.
A resident who chose to end skilled therapy services and transition to private pay was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to inform her of potential financial liability for non-covered services. Although the resident was told her payer source would change, there was no documentation that she was notified of the private pay costs, as confirmed by the Business Office Manager.
The facility did not send required discharge notifications to the LTC Ombudsman for a resident transferred to a psychiatric hospital and failed to provide a bed-hold policy notice to the DPOA of another resident with hemiplegia after hospital transfer. Documentation supporting these notifications was not available, and the omissions were confirmed by the NHA.
A resident with multiple fall risk factors did not consistently have prescribed fall prevention interventions, such as a fall mat and accessible call light, implemented as outlined in the care plan. Observations showed the fall mat was often missing or improperly placed, and the call light was out of reach. Staff confirmed the fall mat was not always returned after meals, resulting in a potential for unmet care needs.
A resident with a history of pressure ulcers developed new and worsening wounds on both heels and toes due to inadequate offloading, insufficient wound care, and lack of cleanliness. Staff were not consistently aware of all wounds, and interventions such as pressure-relieving boots and bed adjustments were not effectively implemented, resulting in preventable skin breakdown.
A resident with a history of muscle weakness and repeated falls was injured after an agency CNA provided bed mobility assistance alone, despite the care plan requiring a two-person assist. The CNA did not review the care plan or consult with staff, leading to the resident falling from the bed and sustaining multiple abrasions.
A resident with end stage renal disease did not receive required post-dialysis assessment and monitoring, as the assigned nurse failed to retrieve and review the dialysis communication form, did not record vital signs, and did not document a progress note after the resident's return from dialysis. The facility's policy for immediate post-dialysis assessment and documentation was not followed.
The facility did not ensure timely follow-up on pharmacist medication regimen review recommendations for three residents, including those with severe cognitive impairment and complex medication regimens. Recommendations to evaluate or discontinue certain medications were not promptly addressed or documented, and required assessments and consents were missing. Staff interviews confirmed lapses in the process for reviewing and implementing pharmacy recommendations, contrary to facility policy.
A resident with Alzheimer's disease, dementia, and hypertension was not properly screened for pneumococcal vaccine eligibility, and there was no documentation that the appropriate vaccine was offered or administered according to CDC guidelines. The resident received two doses of PPSV23, but the facility did not assess or document the need for additional vaccination with PCV20 as required.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall, after which staff noted abrasions and a progressive decline in condition, including increased blood pressure, somnolence, and loss of independence in activities of daily living. Despite these changes, nursing staff did not promptly escalate care or ensure the on-call provider was fully informed, resulting in a delay in hospital transfer and diagnosis of a significant intracranial hemorrhage.
Multiple residents with histories of falls and cognitive impairment experienced unwitnessed falls, including incidents resulting in serious injuries such as intracranial hemorrhage and spinal fractures. Staff failed to provide adequate supervision, did not implement or update individualized care plan interventions after falls, and did not conduct required interdisciplinary reviews. Care plans were found to be too broad and not descriptive enough for staff to follow, and residents did not consistently receive the assistance or supervision required for their safety.
A resident with significant mobility limitations and a history of falls requested help from a CNA to use the restroom, as outlined in her care plan. The CNA refused to assist, telling the resident she needed to be independent, and did not help with transferring or ambulation, leaving the resident to struggle in pain. The resident described the interaction as condescending and demeaning, and the facility had not provided staff training on communication or customer service in the past year.
A resident with depression reported multiple unresolved concerns, including dietary, dental, podiatry, CPAP, medication, therapy, wound care, and activity issues. Despite raising these concerns with leadership and during a care conference, the resident received no updates or resolutions. Staff interviews revealed confusion about the grievance process, and only one grievance form was found, contrary to facility policy requiring the administrator to oversee and track grievances.
A CNA observed a resident touching another resident inappropriately and reported the incident to an LPN, who redirected the resident and documented the event but did not immediately notify the abuse coordinator as required by policy. Multiple staff interviews confirmed knowledge of the immediate reporting requirement, but the LPN stated unawareness of the policy, resulting in delayed notification to the appropriate personnel and authorities.
The facility did not conduct complete investigations into multiple allegations of abuse and neglect, including incidents involving falls, inappropriate resident contact, and rough care by a CNA. Investigation files were missing key documentation such as staff interviews, clinical assessments, and evidence of follow-up, and administrators were unable to provide details or records supporting their investigative processes.
A resident with a history of a resolved Stage 3 heel pressure ulcer and significant mobility limitations was not consistently provided with pressure-reducing devices or proper offloading, despite care plan interventions. Observations showed the resident without heel boots or pillows to elevate his heels, and his feet resting on a bed footboard that was too small for his height. Staff confirmed the resident often removed his boots and alternative measures were not always used, leading to the development of a new facility-acquired pressure ulcer.
Multiple residents experienced neglect and abuse when nursing staff failed to provide care and supervision, resulting in missed medications, medication errors, and an attempted elopement. Staffing shortages and lack of management response left residents without necessary care, while a CNA physically and verbally abused a cognitively impaired resident during personal care, and there were also incidents of resident-to-resident physical abuse.
A resident with severe cognitive impairment was subjected to repeated physical and verbal abuse by a CNA during care, while two other CNAs present failed to intervene or remove the resident from the situation, leaving the resident alone with the abuser and only reporting the incident afterward. Facility policy requiring immediate protection and removal was not followed.
Failure to Transcribe, Implement, and Consistently Provide Ordered Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer care and to prevent worsening of existing pressure injuries for two residents. For one resident with metabolic encephalopathy, hospital discharge paperwork and a handwritten note from hospital staff documented existing skin issues, including a right hip wound and incontinence-associated dermatitis, with specific wound care instructions such as cleansing, Xeroform and foam dressings on a set schedule, frequent turning and repositioning, heel offloading, and use of barrier creams. These instructions were not transcribed into the facility’s physician orders, treatment records, or care plans upon admission. The admission skin assessment documented only a right hip surgical site and did not record any open wounds or refusals for skin assessment, and there were no sacral wound orders or treatments documented for several days after admission. The pressure ulcer care plan for the sacrum was not developed until two weeks after admission, and the incontinence and skin care plans did not reflect the resident’s need for frequent incontinence care or any refusals of care. Subsequent assessments and documentation for this resident showed inconsistent and delayed recognition and treatment of a sacral pressure injury. A new sacral pressure ulcer was first documented days after admission as a Stage 3 pressure ulcer, with measurements and moderate drainage, and wound care orders were initiated the following day. A wound provider later assessed the sacral wound as an unstageable pressure ulcer, noted heavy drainage, and ordered daily dressing changes with Manuka dressing, an APM bed, heel protectors, offloading, and frequent incontinence changes. However, the provider’s daily dressing order was incorrectly entered as every other day, and the TAR showed missed or undocumented treatments, including no documented dressing change on a scheduled day and no PRN wound care orders. Staff interviews revealed that the resident was very hard to reposition, required two-person assistance, was incontinent, and did not refuse care, and CNA documentation showed no refusals of incontinence care. A CNA reported finding a large sacral dressing that was foul-smelling and urine-soaked, notifying an LPN twice, and observing that the dressing remained unchanged for many hours; another LPN later changed the dressing without cleansing the wound. The resident’s change in mental status and suspected sepsis from the coccyx wound were documented only shortly before transfer to the hospital, where the sacral ulcer was described as a large, foul-smelling, unstageable pressure sore with black eschar and sepsis secondary to the sacral decubitus ulcer. For a second resident with a right heel pressure injury, the facility failed to provide consistent wound care as ordered, resulting in deterioration and infection of the heel wound. The pressure ulcer care plan identified a right heel pressure injury and called for wound care per physician orders and weekly skin evaluations, but wound provider notes over several months documented that dressings were grossly soiled, left in place far beyond the ordered change frequency, and not consistent with the prescribed products. The wound provider repeatedly noted missed dressing changes, wrong dressings, deterioration of the wound, strong odor, and concerns for cellulitis and infection, and ordered systemic and topical antibiotics and more frequent dressing changes. Review of physician orders and treatment records showed multiple missed and refused treatments across three months, with no corresponding progress notes or documentation of PRN wound care or re-attempts after refusals. Staff interviews indicated that some nurses, including agency staff, were unaware of the resident’s wound or dressing orders, that dressing changes were typically assigned to night shift, and that the resident did not usually refuse care, despite multiple refusals being recorded without supporting narrative documentation. These actions and omissions led to worsening of the resident’s unstageable right heel pressure injury and required antibiotic interventions for infection. The facility’s internal nursing leadership acknowledged awareness of ongoing issues with wound care not being completed as ordered for multiple residents, including missed dressing changes, incomplete documentation, and lack of availability of ordered wound care products. The ADON, who managed wounds, reported not reviewing the first resident’s hospital discharge paperwork until after the wound had already worsened and acknowledged that wound orders from the hospital should have been entered on admission. She also reported discovering months earlier that other residents were not receiving ordered wound care and that she and the unit manager had been monitoring for missed treatments. The DON confirmed that there were no documented refusals of incontinence or wound care for the first resident and that she was aware of prior problems with wound care not being completed. The administrator reported that wound-related QAPI discussions had focused only on the number of wounds, not on missed or incomplete wound care, indicating that the documented failures in assessment, order transcription, treatment implementation, and monitoring directly contributed to the cited deficiencies in pressure ulcer care for both residents.
Failure to Keep Call Light Within Reach of a Bedbound Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by the resident’s care plan and facility expectations. The resident was a female with diagnoses including other recurrent depressive disorders, generalized muscle weakness, difficulty in walking, and cognitive communication deficit, and had a care plan focus of being at risk for falls due to a history of falls. The care plan, revised on 11/9/25, included an intervention to orient the resident to her surroundings and the use of the call light, initiated on 4/24/25. On multiple observations over two consecutive days, the resident was seen in bed with her call light not visible and hanging on the bottom of the bed frame behind the head of the bed near the floor, out of her reach. This positioning of the call light was documented at 9:27 AM, 11:07 AM, and 2:54 PM on 3/4/26, and again at 8:49 AM on 3/5/26. In interviews, CNAs and the ADON consistently reported that call lights were supposed to be within physical reach of residents, placed on or near their body so they could touch and activate them, and confirmed that it was not acceptable for the call light to be behind the resident on the bed frame near the floor. One CNA reported she had just found the resident’s call light in that inaccessible location and confirmed the resident did use her call light sometimes.
Incomplete and Inaccurate Wound Care Documentation for Heel Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and treatment documentation for a resident with a right heel pressure injury. The resident was admitted with weakness and falls and had an active care plan for a right heel pressure injury requiring wound care per physician orders and weekly skin evaluations. Review of physician orders and treatment records from December through February showed multiple missed and refused wound care treatments without corresponding progress notes or documentation of PRN wound care, despite orders specifying every other day, then daily wound care, and checks of dressing placement. The care plan also called for weekly full skin checks, but several of these were not completed on specified dates. The Unit Manager stated she was aware of issues in December and January with wound dressings not being changed and incomplete documentation, and confirmed that refusals of wound care in February were not supported by progress notes or documentation of re-attempts. The Nurse Practitioner reported that on two separate visits, the resident’s right heel dressing was grossly soiled, had not been changed for several days beyond the ordered frequency, and did not match the ordered dressing type on one occasion. The NP documented concern for cellulitis, ordered oral antibiotics, and later added a topical antibiotic and daily dressing changes when the wound deteriorated, but on a subsequent visit again found a soiled dressing that had not been changed as ordered and noted the topical antibiotic was not available. Medication records showed the resident did not receive all ordered doses of oral antibiotics in both December and January. Additionally, a Treatment Administration Record entry showed that an LPN documented checking the placement of the right heel dressing, but in interview that LPN stated she was not aware of a wound dressing on the resident, despite having documented the check that same morning. The ADON acknowledged finding the resident’s dressing not changed, missing documentation, and documentation indicating dressings had been changed more than once in the past, and was aware that the wound care provider had previously been upset about dressings not being changed as ordered.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident having a documented full code status. The assigned agency RN did not perform CPR upon discovering the resident unresponsive and without vital signs, and instead pronounced the resident deceased. The nurse stated she was informed the resident was on hospice and did not recall the code status, leading to no resuscitative efforts being made. Other staff, including CNAs, were aware of the resident's full code status and expected that CPR should have been started, but no action was taken to initiate a code or call emergency services. The resident involved had a history of hereditary ataxias, dysphagia following cerebral infarction, and Parkinson's disease, and was admitted to hospice services with a clear advance directive indicating full cardiopulmonary resuscitation. Despite this, the care plan did not document the code status or advance directives, and the nurse relied on verbal information about hospice status rather than verifying the resident's documented wishes. The nurse did not check the medical record or care plan for code status before deciding not to initiate CPR. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, with some staff assuming hospice status equated to a do-not-resuscitate (DNR) order. The facility's policies required CPR to be initiated for full code residents unless a DNR order was present and documented. The failure to follow these policies and verify the resident's code status resulted in the resident not receiving basic life support prior to death.
Removal Plan
- All resident charts were audited to confirm code status based on Resident/POA wishes.
- Facility licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- Agency licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.
- The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.
- The medical director was notified.
- The Director of Nursing held mock CPR drills with nursing staff on each shift.
- Director of Nursing will conduct mock CPR drills monthly on each shift.
- Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.
- An Ad-Hoc QAPI meeting was held to review findings and action plan.
Failure to Protect Residents from Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from both resident-to-resident and staff-to-resident physical abuse, as evidenced by multiple incidents involving three residents. One incident involved a resident with Alzheimer's disease and dementia who was struck in the mouth by another resident with a known history of aggression and behavioral disturbances. Documentation and interviews revealed that the aggressive resident had exhibited repeated episodes of anger, verbal and physical aggression, and difficulty with redirection in the weeks leading up to the incident. Despite these documented behaviors, there was no behavior care plan implemented prior to the altercation, and staff supervision was reported as insufficient, particularly when staffing levels were low or when unfamiliar staff were present on the unit. Another incident involved a cognitively intact resident who reported being struck in the face by an agency LPN during an argument about the administration of an insulin injection. Multiple interviews with staff and witnesses confirmed that a physical altercation occurred, with the resident sustaining a bloody lip and both parties engaging in yelling and physical contact. The LPN admitted to pushing the resident's hands away after being poked in the chest, and a police report classified the event as a simple assault. The facility's investigation into this incident was incomplete, as only one written witness statement was collected and not all available witnesses were interviewed. The facility's abuse prevention policy requires ongoing assessment, care planning, and monitoring of residents with behavioral issues, as well as immediate reporting and investigation of abuse allegations. However, the facility did not implement appropriate interventions or supervision for residents with known aggressive behaviors, nor did it conduct a thorough investigation into the staff-to-resident abuse incident. These failures resulted in residents being exposed to physical harm and not being protected from abuse as required by facility policy and regulatory standards.
Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for two residents, resulting in missing controlled substances and incomplete documentation. During the discharge process for one resident, discrepancies were identified in the narcotic card and sheet counts, with three cards missing and no documented explanation for their removal. The agency RN involved could not account for the missing medications or provide details on the disposition of the blister packs and count sheets. The controlled substance shift inventory sheets were not properly completed, with missing signatures and blank sections where explanations should have been provided. One resident was admitted for a respite stay under hospice care and had orders for hydrocodone-acetaminophen. Pharmacy records indicated a specific quantity of medication was received, but the medication administration record only documented the administration of three tablets during the stay. The controlled substance inventory showed a reduction of three cards without corresponding documentation or explanation. The former DON confirmed that the medications and count sheets were missing and could not be located after an internal investigation. A second resident, admitted with multiple injuries and prescribed oxycodone, also had missing narcotic medications. Pharmacy records and medication administration records did not account for all tablets received, and witness statements confirmed that medications for both residents were unaccounted for. Interviews with staff revealed that the required shift-to-shift controlled substance counts were not consistently signed by both incoming and outgoing nurses, contrary to facility policy. The facility's policy required immediate reporting and documentation of unresolved discrepancies, which was not followed in these instances.
Failure to Thoroughly Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving one resident. The resident reported that during an argument with an agency LPN, he was struck by the nurse after he pushed the LPN. The incident occurred after the resident requested an insulin injection in the dining area, which the LPN refused, leading to a confrontation in the resident's room. Multiple witnesses, including a CNA and a family member, reported hearing or observing the altercation, with one CNA noting the resident had a bloody lip and stating that both the resident and LPN admitted to physical contact. A police report also documented the incident, with the LPN admitting to slapping the resident's hand away after being poked in the chest. Despite these accounts, the facility's investigation was incomplete. The interim DON only collected a written statement from one CNA and did not interview all staff or witnesses present during the incident, including another CNA and a family member who directly observed or heard the altercation. The facility's abuse policy requires a thorough investigation, including interviewing all involved persons and witnesses, but this was not followed. As a result, the incident of staff-to-resident physical abuse was not fully identified or documented, and there was a potential for additional abuse to go unrecognized.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for a resident with multiple cardiovascular diagnoses, including paroxysmal atrial fibrillation, pulmonary embolism, popliteal vein thrombosis, hypertension, heart failure, and hypotension. The resident had physician orders for Midodrine to be given with meals for hypotension, to be held if systolic blood pressure was greater than 130, and for Metoprolol to be given once daily for cardiac arrhythmia, to be held if systolic blood pressure was less than 100, diastolic blood pressure less than 60, or heart rate less than 55. The orders also specified that Midodrine and Metoprolol should not be administered at the same time per the cardiologist. Observation and interviews revealed that an LPN administered both Metoprolol and Midodrine together at 9:39 AM, with the Midodrine being given late (scheduled for 8:00 AM) and not with a meal as ordered. The LPN acknowledged the error, stating that medication administration was difficult due to frequent interruptions. The unit manager confirmed that the medications were administered together, contrary to the physician's order, and explained that the medications have opposing effects on blood pressure and heart rate. The failure to follow the physician's orders and professional standards resulted in the resident not receiving medications as intended.
Failure to Provide Consistent Assessment, Monitoring, and Treatment for Resident with Complex Needs
Penalty
Summary
A resident with a complex medical history, including chronic lymphedema, morbid obesity, heart failure, chronic constipation, and hyperkalemia, experienced multiple failures in care delivery. The facility did not consistently assess, monitor, document, or provide treatment according to professional standards and physician orders. The resident reported significant pain from constipation and requested an enema, which was refused by nursing staff despite her history of fecal impaction. She was later hospitalized for fecal impaction and dangerously high potassium levels. Hospital records confirmed severe constipation, hyperkalemia, and the need for disimpaction and urgent medical intervention. The resident also reported that wound care was not being provided as ordered. She had open, weeping areas on her legs due to lymphedema, and facility staff used incontinence briefs instead of prescribed wound dressings when supplies ran out. The resident stated that she often had to clean her own wounds, and there were periods when the wound nurse did not assess her skin as scheduled. Documentation and interviews confirmed missed applications of compression stockings and lymphedema boots, with no progress notes indicating resident refusal. Supply orders for wound care were not consistently maintained, leading to lapses in appropriate wound management. Review of the Medication Administration Records (MAR) revealed multiple missed treatments, including compression stockings and lymphedema boots, without documentation of resident refusal. There were also inconsistencies in the administration and documentation of bowel management interventions, such as enemas and laxatives. Staff interviews indicated a lack of communication and follow-through regarding supply shortages and resident care needs. These failures resulted in the resident's hospitalization and ongoing issues with wound care, bowel management, and monitoring of critical lab values.
Failure to Provide Proper External Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a female resident using a Pure Wick external urinary catheter. The resident, who had diagnoses including acute cystitis with hematuria, overactive bladder, neuromuscular dysfunction of the bladder, and was a carrier of carbapenem-resistant enterobacterales (CRE), reported that staff did not respond promptly to her requests for assistance. She described being left in feces for extended periods, sometimes up to five hours, and noted that the Pure Wick device was not always functioning properly, leading to leakage and the need for additional pads. The resident also had to instruct CNAs on how to properly reattach tubing and clean the canister, indicating a lack of staff competency and adherence to proper procedures. Observations and interviews revealed that the Pure Wick canister was often left full or over halfway full, and staff did not consistently empty or clean it as required. The resident reported that the canister had not been cleaned for two or three days at times, and staff were not coming in to provide care until late in the evening. The Unit Manager acknowledged there were no specific orders or protocols in the resident's record regarding cleaning the Pure Wick canister, when to empty it, or when to replace the canister and tubing. Additionally, there was no documentation of staff education or resident monitoring related to the use and care of the Pure Wick system, despite the resident's history of multiple urinary tract infections and CRE. Review of facility policy and manufacturer guidelines confirmed that the Pure Wick external catheter should be replaced every 8 to 12 hours or immediately if soiled, and that canisters and tubing should be cleaned and disinfected at least daily and replaced every 60 days. However, the facility's practice did not align with these standards, as staff were not consistently following the required procedures for replacement, cleaning, and monitoring. The Director of Nursing was unable to confirm whether staff were ensuring timely replacement of the external catheter or proper documentation, and there was a lack of clear protocols and staff education regarding the care of the Pure Wick system.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current daily nurse staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors. Observations on multiple dates revealed that outdated staffing information was displayed, with staffing hours from previous days remaining posted for extended periods. On several occasions, the most current staffing hours were not posted as required, and the information available was several days old. The postings were located in a glass-enclosed bulletin board behind the entryway and reception area, but due to a missing key, updated postings were taped to the outside of the enclosure rather than placed inside. Interviews with facility staff confirmed that the responsibility for posting staffing hours had recently transitioned from one staff member to another. The new scheduler acknowledged that the postings were not being updated regularly and admitted that the current day's staffing hours had not yet been posted at the time of the surveyor's inquiry. The Nursing Home Administrator also confirmed that staffing hours were supposed to be posted daily and recognized that the postings were not current during the surveyor's visit.
Failure to Honor Resident Food Choices and Menu Consistency
Penalty
Summary
The facility failed to ensure that a resident's food choices were consistently obtained and honored, resulting in dissatisfaction with meal services and the potential for inadequate food or fluid intake. The resident, who had a complex medical history including iron deficiency, slow transit constipation, mixed irritable bowel syndrome, lymphedema, CHF, morbid obesity, recurrent UTI, hypertension, depression, and a history of pressure injuries, was on a regular vegetarian diet and was supposed to be offered food and beverage selections with substitutes as requested. Despite this, the resident reported not receiving planned menu items on multiple occasions, such as the Christmas lunch meal and lentil meatloaf, and expressed frustration over the lack of suitable vegetarian options and necessary condiments for her meals. Interviews with dietary staff and the registered dietician revealed that errors in ordering and meal preparation contributed to the resident not receiving her selected meals. The dietary manager admitted to forgetting to order specific items, and the registered dietician confirmed that some preferred items were not available from the supplier, requiring alternative discussions with the resident. The resident also reported feeling that she was expected to supply her own food due to the limited vegetarian options available, and staff acknowledged lapses in providing the correct menu items as ordered.
Failure to Provide Supervision During Toileting Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, abnormal gait, chronic pain, and a history of falls was left unsupervised on a bedside commode. The resident was dependent on two staff members for all activities of daily living and was unable to make her needs known or use a call light. Despite these needs, the resident was left alone on the commode after a shift change, with staff only nearby outside the room and not within arm's reach. The incident was discovered when a registered nurse heard a loud noise and found the resident lying on the floor in front of the commode. The resident sustained a closed comminuted fracture of the left patella and a closed head injury, as confirmed by hospital records. Interviews with staff and the resident's guardian confirmed that the resident should not have been left unattended due to her cognitive and physical limitations, and that her care plan required staff to anticipate her needs and provide safety and comfort. Facility documentation, including the fall risk assessment and care plan, indicated the resident was at high risk for falls, had poor safety awareness, and required staff assistance for toileting. The facility's ADL policy also required appropriate support for residents unable to carry out activities independently. The failure to provide direct supervision during toileting led to the resident's unwitnessed fall and subsequent injuries.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an injury of unknown origin sustained by a resident. The resident, who had chronic pain, vascular dementia, and was dependent for all activities of daily living, was found to have a nondisplaced distal radius fracture after being transferred to the hospital. The hospital records indicated swelling, tenderness, and pain in the resident's left arm, with imaging confirming a concerning lucency in the distal radius. Despite these findings, the facility did not report the injury of unknown origin to the state agency as required by their abuse policy and federal regulations. The facility's internal investigation into the incident did not address the injury of unknown origin, even though the hospital records noting the fracture were present in the facility's incident folder. Interviews revealed that the administrator and medical director did not review or recognize the x-ray findings indicating a possible fracture. The administrator confirmed that such an injury should have been reported to the state agency but was unable to explain why this was not done. The family member of the resident also reported concerns about the injury, noting the resident's inability to self-inflict such harm due to being bedbound and dependent on staff for care. The facility's abuse policy required immediate reporting of any allegations or reasonable suspicions of abuse, neglect, or injuries of unknown source to the state agency and other authorities. However, the injury was not reported as required, and the investigation did not address the injury of unknown origin. This failure to report and investigate the injury in accordance with policy and regulatory requirements constituted the deficiency identified by surveyors.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and thoroughly investigate an injury of unknown origin for a resident who was dependent on staff for all activities of daily living due to chronic pain, vascular dementia, and multiple amputations. The resident was re-admitted to the facility following a lengthy hospitalization and was noted to be bed bound, requiring total assistance from staff. During a subsequent hospital visit, the resident was found to have a nondisplaced distal radius fracture, as confirmed by x-ray findings in the hospital records. Family members and staff interviews indicated that the resident had been in pain and exhibited swelling in the affected arm, but the source of the injury was not clear, and the resident was unable to communicate the cause due to cognitive and language barriers. Despite the presence of hospital records in the facility's incident investigation folder that documented the injury, the facility did not address or investigate the injury of unknown origin in its report to the State Agency or as part of its internal investigation. The Director of Nursing and the Nursing Home Administrator both confirmed that they were unaware of the fracture documented in the hospital records, and the hospital x-ray findings were not fully reviewed by the facility's medical director or administration. The facility's investigation focused on allegations of neglect and abuse but did not include a review or investigation of the resident's wrist injury, even though the resident was entirely dependent on staff for care and unable to self-inflict such an injury. The facility's abuse policy required a timely, thorough, and objective investigation of all alleged violations, including injuries of unknown source, and mandated reporting to the State Agency. However, the investigation did not identify or address the injury, did not include a review of all relevant medical records, and did not determine the cause or extent of the injury. As a result, the injury of unknown origin was not investigated as required by facility policy and regulatory standards.
Failure to Assess, Monitor, and Treat Pressure Ulcer Results in Worsening Wound
Penalty
Summary
A resident with reduced mobility and type 2 diabetes was identified as being at high risk for skin breakdown, as indicated by a Braden score of 11. The resident's care plan included multiple interventions for skin integrity, such as the use of an alternating pressure mattress, barrier cream, regular turning and repositioning, and daily skin monitoring. Despite these interventions being listed, the care plan was not updated upon the resident's re-admission, and there was a lack of follow-through in implementing and documenting appropriate wound care interventions. On assessment, the resident was found to have a wound on the coccyx, initially documented as moisture-associated skin damage (MASD) with incontinence-associated dermatitis (IAD). The wound was present on admission, but no treatment orders were obtained or implemented for this wound. Staff interviews revealed that both nursing assistants and nurses observed an open area on the coccyx, described as red and larger than a quarter, but the nurse who assessed the wound did not notify the provider or obtain specific treatment orders. Instead, a barrier cream and gauze were applied without clear documentation of the type of cream used, and the provider was not informed to establish a formal treatment plan. Further review showed that the wound worsened, as documented during a subsequent hospital visit, where multiple chronic shallow pressure ulcers were noted, and the coccyx wound was described as much worse than previously observed. The wound care provider confirmed not having assessed the resident, and the facility's own guidelines required provider-ordered treatments for wounds, which were not followed. The Director of Nursing and Assistant Director of Nursing acknowledged that treatment orders were missed and that the wound care team had not seen the resident as expected.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved. No further information about the circumstances, individuals affected, or observations made by surveyors is included in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information or ensuring proper documentation of resident records were not followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to inform and accommodate a resident's responsible party (RP), who is also the legal guardian, in the development and implementation of the resident's person-centered care plan. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and schizoaffective disorder, was readmitted to the facility from a psychiatric hospital. The care plan indicated that the RP should be kept informed of changes in health and medical status to assist with ongoing care planning and decision-making. However, the RP reported that communication from the facility had declined since a change in ownership, and she was not being given the opportunity to participate in care planning as required. The RP had arranged to attend a scheduled care conference in person, but was told by the facility's social worker to cancel, with the promise of a phone call at the scheduled time. The social worker called earlier than scheduled, and when the RP missed the call and attempted to return it, she received no response. The care conference was documented as attended by the RP, but the RP stated she did not participate and was not contacted afterward despite leaving messages. The facility's policy requires advance notice and participation of the resident or RP in care planning, which was not followed in this instance.
Call Light Not Accessible to High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by facility policy. The resident, who had diagnoses including lack of coordination, epilepsy, muscle weakness, and difficulty walking, was dependent on staff for toileting, personal hygiene, and required substantial assistance with dressing. During an observation, the resident was found sitting at the edge of his bed, appearing weak and shaky while attempting to stand up unassisted. The resident repeatedly stated he needed help but was unable to use his call light because he did not know where it was. It was observed that the call light was under the bed and out of the resident's reach. In an interview, a registered nurse confirmed that the resident was a high fall risk and had recently experienced unwitnessed falls in the facility. The nurse also stated that the resident typically used his call light for assistance. Review of the facility's call light policy indicated that staff are responsible for ensuring call lights are plugged in, functioning, and within reach of residents. The failure to provide the resident with access to the call light resulted in the resident's inability to call for staff assistance.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from separation, including separation from other residents, their own rooms, or confinement to their rooms. The report notes that the facility failed to ensure that each resident was protected from such separation or confinement, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or their medical conditions at the time of the event.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Enhanced Barrier Precautions and Water Management Protocols
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) according to facility policy and CDC guidance for three out of four residents reviewed. In one instance, a nurse performed nephrostomy care and flushed nephrostomy tubes for a cognitively intact female resident with multiple comorbidities, including obstructive uropathy and wounds, without donning a gown as required. The resident reported that staff inconsistently wore gowns during her care. The nurse stated she did not believe a gown was necessary unless there was splashing, despite facility policy requiring gown and glove use for high-contact care. Another resident with chronic kidney disease and a hemodialysis catheter was repositioned and checked for wounds by a CNA who wore gloves but not a gown, under the mistaken belief that the resident was no longer on precautions, despite active EBP orders. A third resident with a stage 3 pressure ulcer received wound care from a nurse who wore gloves but not a gown and was unaware of EBP requirements, having not received facility education on the policy. Additionally, the facility did not maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in premise plumbing. Multiple janitors' sinks and spa tubs throughout the facility were observed with issues such as brown or discolored water, stagnant water lines, and lack of flushing schedules. Some sinks did not dispense water from certain handles, indicating stagnant lines, and some tubs and sinks were not regularly used or flushed. The Director of Facilities confirmed that not all areas were on a flushing schedule and that the facility did not routinely test for residual disinfectants in the water supply, despite having a test kit available. Review of facility policies confirmed that EBP requires gown and glove use for high-contact activities for residents with wounds or indwelling devices, and that the water management program requires control measures, testing protocols, and documentation for water safety. However, staff interviews and observations revealed gaps in knowledge, inconsistent implementation of precautions, and lack of adherence to water management protocols.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not properly labeled, dated, or stored in accordance with facility policy and professional standards. On the 400 hall medication cart, a bottle of nitroglycerin was found with an expired discard date, and two opened insulin pens (Lantus and Humalog) lacked open dates. Additionally, an opened lidocaine cream was missing both a resident name and an open date. Nursing staff confirmed that all medications should be labeled with the resident's name and the date opened, and that expired medications should be removed from the cart. On the 300 hall cart, two opened bottles of Genteal tears eye drops were found without resident names or open dates, and an opened insulin pen was missing an open date, making it unclear if it was safe to use. Staff interviews confirmed these labeling and dating requirements were not met. Further, an unlocked medication cart was observed in the hallway near the 300 Hall, with the narcotic drawer pulled open and no staff present to supervise. The cart was later secured by a nurse, who confirmed that medication carts should be locked when not in use. Review of the facility's policy indicated that all medications and biologicals are to be stored in locked compartments to ensure safety and security, which was not adhered to during the observations.
Failure to Offer and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered to eligible residents, as required by their policy and CDC/FDA guidelines. Specifically, three residents with significant medical histories, including conditions such as stroke, Alzheimer's disease, anemia, diabetes, and high blood pressure, did not have documentation in their medical records indicating that they were offered or administered COVID-19 vaccinations beyond 2022. For two residents, the last recorded COVID-19 vaccinations were in October 2022 and March 2022, respectively, with no further information about subsequent offers or administration. For the third resident, there was no documentation of any COVID-19 vaccination being offered or administered at all. Interviews with the Infection Preventionist confirmed that COVID-19 vaccinations are supposed to be offered upon admission and annually as the vaccine changes, but no additional documentation could be provided to show that these three residents were offered the vaccine after 2022. At the time of the survey, all three residents were eligible to receive the COVID-19 vaccination, but the facility lacked evidence that the required education and offer of vaccination had occurred as per policy.
Failure to Maintain Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure a fully functioning call light system was available and operational for all residents, specifically affecting four residents out of eighteen reviewed. Multiple residents reported that their call lights were either not working properly or not being answered in a timely manner. Observations confirmed that in several cases, the call light would activate inside the resident's room but would not trigger the hallway indicator to alert staff, and in some instances, the call light remained on even after staff attempted to turn it off. Additionally, some residents reported that their call lights were placed out of reach, preventing them from calling for assistance when needed. Interviews with residents revealed ongoing issues with the call light system, including long wait times for staff response and instances where no one responded at all. One resident reported waiting approximately two hours for assistance, while another stated that the call light system in her room frequently did not work and was often out of reach. Family members and roommates corroborated these accounts, noting repeated problems with the call light system and the need for residents to call out for help when the system failed. Facility staff, including the Director of Facilities and the DON, acknowledged awareness of the call light system's deficiencies. The facility had previously attempted to use cell phones as part of the system, but these were not functioning properly and were discontinued. The monitoring screen for call lights had also been placed in a location not visible to staff at the nurse's station until recently. Work orders confirmed repeated maintenance requests for the malfunctioning call light system in affected rooms, but issues persisted, resulting in residents' needs potentially going unmet.
Failure to Provide Mandatory Infection Control and EBP Training to Agency Staff
Penalty
Summary
The facility failed to implement an effective infection prevention and control training program, specifically regarding Enhanced Barrier Precautions (EBP), for agency staff. Record review and interviews revealed that four out of five staff members reviewed did not receive or complete required education on EBP prior to working shifts. The Infection Preventionist stated that agency staff were expected to review a binder containing EBP policies at the facility entrance, but there was no process in place to verify or document that this education was completed. Agency staff reported either not being informed about the binder, not receiving any EBP education, or only being asked to review unrelated materials such as the narcotic binder. Additionally, an agency RN preparing to perform wound care was unaware of the need to wear a gown and was not familiar with EBP, stating that she had not received any relevant education from the facility. This lack of training and verification created the potential for cross-contamination and the spread of infection among a vulnerable population, as staff were not adequately prepared to follow infection control protocols.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as required by policy. During an observation, a CNA referred to residents with the label "lay backs" in a public hallway while pointing to three residents who were seated in geri chairs near the nurses' station. This comment was made in the presence of other staff and residents, and the Director of Nursing later confirmed that such language is not appropriate and does not align with facility policy, which mandates respectful communication and addressing residents by their preferred names. The residents involved had significant cognitive impairments, including diagnoses of major depressive disorder, anxiety disorder, Alzheimer's disease, and dementia. Two of the residents were moderately cognitively impaired, while one had severely impaired cognitive skills and was unable to participate in a mental status interview. The incident was observed and documented by surveyors, and attempts to interview the CNA involved were unsuccessful prior to the survey exit. The facility's own dignity policy emphasizes the importance of promoting residents' well-being and self-worth, which was not upheld in this instance.
Failure to Obtain Psychotropic Medication Consent Prior to Administration
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia, depression, and anxiety, was unable to clearly verbalize needs and frequently refused care. Despite being prescribed multiple psychotropic medications such as Lexapro, Risperidone, Trazodone, and Ativan, there was no documentation of signed or verbally discussed consents for these medications prior to their administration. Record review confirmed the absence of psychotropic medication consents, and staff interviews verified that no consents were on file before a specified date. The resident's care plan included interventions to provide education on the risks and benefits of these medications, but there was no evidence that this was carried out as required by facility policy. This resulted in the resident and/or their representative not being fully informed about the medications being administered.
Failure to Notify DPOA of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's durable power of attorney (DPOA) or emergency contact after the resident experienced a fall and was transferred to the hospital. The resident, who had a history of muscle weakness and hemiplegia following a cerebral infarction, was found on the floor next to her bed with a large bruise on her right knee and a bump and bruise on the left side of her forehead. The LPN on duty initiated neurological assessments, contacted the on-call provider, and arranged for the resident to be transported to the hospital due to concerns about a possible head injury. However, there was no documentation that the resident's DPOA was notified of the incident or the hospital transfer. Interviews with the family member, LPN, DON, and regional nurse consultant confirmed that the DPOA was not contacted regarding the fall and subsequent hospital transfer. The facility's own policy requires notification of the resident's designated representative in the event of an accident or incident resulting in injury and requiring physician intervention or transfer. Review of the incident report and progress notes did not show evidence of such notification, and the family member only learned of the incident after being contacted by the hospital.
Failure to Issue SNF ABN for Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who transitioned from Medicare-covered skilled care to private pay after choosing to discontinue therapy services. Documentation showed that the resident was informed on her last covered day that her payer source would change to private pay, but there was no record of an SNF ABN being issued to notify her of potential financial liability for non-covered services. The Business Office Manager confirmed that the resident should have received an ABN but did not, and there was no documentation indicating the resident was informed of the private pay costs.
Failure to Provide Required Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required discharge notifications and bed-hold policy information for two residents during the discharge process. For one resident with a history of anxiety and depression, the State Long-Term Care (LTC) Ombudsman did not receive notification of the resident's discharge to a psychiatric hospital. The Nursing Home Administrator (NHA) was unable to provide documentation that notifications were sent to the ombudsman's office, and the resident was not listed on the facility's discharge log for the relevant month. Interviews and record reviews confirmed that the required notification was not completed. For another resident with muscle weakness and hemiplegia following a cerebral infarction, the facility did not provide the resident's Durable Power of Attorney (DPOA) with written notice of the bed-hold policy when the resident was transferred to the hospital. The NHA confirmed that the bed-hold notice was not provided. These failures were identified through interviews, record reviews, and correspondence with the LTC Ombudsman.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at risk for falls due to multiple factors, including medication side effects, debility, poor oral intake, ataxia, impaired safety awareness, visual impairment, and osteoporosis. The resident's care plan included specific interventions such as keeping the call light within reach and ensuring a fall mat was placed next to the bed. However, during multiple observations, the fall mat was either missing, improperly positioned, or folded against the wall, and the call light was found out of the resident's reach. Staff interviews confirmed that the fall mat was often moved to accommodate the bedside table during meals and was not consistently returned to its proper position afterward. A CNA acknowledged that staff frequently forgot to replace the fall mat after the resident finished eating, resulting in the resident being left without the prescribed fall prevention intervention. These lapses in following the care plan created a potential for unmet care needs for the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of unstageable pressure ulcers to the heels was not provided with adequate care and services to prevent the development and worsening of pressure injuries. The resident was observed multiple times with his feet pressed against the footboard of a bed that was too short, resulting in wounds on both heels and toes. The resident reported pain and that his feet were not being cleaned as needed, and observations confirmed the presence of open, bleeding, and scabbed wounds on his heels and toes, as well as soiled pressure-relieving boots and bedding. Nursing and agency staff were not consistently aware of all the resident's wounds, with some staff unaware of wounds on the toes and wound care orders not covering all affected areas. Wound assessments and documentation showed a lack of timely identification and treatment of new or worsening wounds, including a newly developed unstageable pressure injury to the right heel and scabbed, bleeding toes. The resident's care plan included the use of foam heel suspension boots and offloading, but these interventions were not consistently or effectively implemented, as evidenced by the resident's ongoing contact with the footboard and the condition of his feet. Record review indicated that the resident had a history of pressure injuries to both heels and toes, with recommendations for offloading and repositioning. Despite these recommendations, the resident continued to experience preventable skin breakdown due to inadequate offloading, insufficient wound care, and lack of cleanliness. The failure to provide necessary care and services consistent with professional standards resulted in the development of new pressure injuries and the potential for further harm.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of muscle weakness and repeated falls was not provided the care as outlined in his care plan. The resident required assistance from two staff members for bed mobility, as documented in his care plan and Kardex. However, on the date of the incident, an agency CNA provided care alone and attempted to move the resident in bed without the required second staff member present. During this process, the resident fell from the bed, resulting in abrasions to his face, knees, and a bleeding wound on his toe. The incident report and interviews confirmed that the CNA did not review the care plan or Kardex prior to providing care and did not consult with nursing staff or other personnel before proceeding. The resident was found on the floor, partially under the bed, after the fall. The DON confirmed that the CNA was alone in the room at the time of the incident, which was not in accordance with the resident's care plan requirements for a two-person assist during bed mobility.
Failure to Monitor and Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end stage renal disease who required hemodialysis. The resident's care plan included interventions such as monitoring for signs and symptoms of infection, renal insufficiency, bleeding, and other complications, as well as specific instructions not to draw blood or take blood pressure in the arm with a graft. Despite these interventions, there was no evidence that the resident was assessed or monitored upon return from dialysis on multiple occasions. The dialysis communication form was not immediately retrieved or reviewed by the assigned nurse, and vital signs were not recorded regularly, with the most recent entry being a month prior to the incident. Progress notes for the days the resident returned from dialysis were also missing. Interviews with staff revealed that the nurse assigned to the resident was unfamiliar with the resident and did not receive or review the dialysis communication form. The Director of Nursing confirmed that the form was later found in the resident's wheelchair pocket and acknowledged that the nurse did not monitor the resident or document a progress note after dialysis. The facility's policy required immediate retrieval of the dialysis communication form, assessment of the resident's stability, and documentation in the medical record, none of which were followed in this instance.
Failure to Address Pharmacist Medication Review Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for several residents, resulting in recommendations not being addressed in a timely manner. For one resident with severe cognitive impairment and diagnoses including dysphagia and dementia, the pharmacist repeatedly recommended evaluation and possible discontinuation of Nystatin-Triamcinolone cream and Acidophilus, as their continued use was not supported. Although the provider agreed with the recommendations, there was no documentation of timely follow-up or physician review, and the medications were not discontinued until much later than when the recommendations were signed. Another resident with severe cognitive impairment and multiple psychotropic medications did not have required Abnormal Involuntary Movement Scale (AIMS) assessments documented, and the facility was unable to produce MRR irregularity reports for review. Interviews revealed that the process for reviewing and implementing pharmacy recommendations had not been followed for at least two months, with reports not being reviewed or acted upon in a timely fashion. Additionally, medication consents were not on file for this resident prior to a certain date. A third resident with Alzheimer's disease and major depressive disorder had a pharmacist recommendation to evaluate the continued need for Vitamin B-12 and Lipitor due to terminal status, but there was no evidence that the physician or provider reviewed or responded to this recommendation. Interviews with facility staff confirmed a lack of awareness and follow-up regarding these recommendations. The facility's policy required that physicians document review and action on any pharmacist-identified irregularities by their next mandatory visit, but this process was not followed for the residents in question.
Failure to Screen and Document Pneumococcal Vaccination Eligibility
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive pneumococcal vaccinations and to document the administration or offer of the vaccine in accordance with facility policy and CDC guidelines. Review of the resident's medical record showed no documentation of screening for pneumococcal vaccination eligibility, and no record that the resident was offered the vaccine as recommended. Although a consent for vaccination was signed in 2022, there was no clear documentation of follow-up screening or administration of the appropriate pneumococcal vaccine. Further review revealed that the resident received two doses of the same pneumococcal polysaccharide vaccine (PPSV23) on separate occasions, but there was no evidence that the facility assessed the need for additional or different pneumococcal vaccines as per current recommendations. The lack of documentation and screening resulted in the resident not being offered the Prevnar 20 (PCV20) vaccine in a timely manner, as required by CDC guidelines for adults of her age and vaccination history.
Delayed Identification and Treatment Following Unwitnessed Fall
Penalty
Summary
A resident with a history of falls, dementia, and previous intracranial hemorrhage experienced an unwitnessed fall in the facility's bathroom. The resident was found on the floor by a CNA, with abrasions noted on the elbows, knees, and later, the forehead. The resident denied hitting his head and initially did not report pain, but over the following days, staff documented significant changes in condition, including increased blood pressure, facial grimacing, refusal to eat, increased need for assistance with activities of daily living, and increased somnolence. Despite these changes, the resident was not immediately sent to the hospital. Nursing staff communicated with the on-call provider, a Physician Assistant (PA), about the resident's symptoms, but the PA was not made fully aware of all the changes, such as the increased blood pressure and the full extent of the resident's decline. The PA ordered a chest x-ray due to a cough and instructed continued monitoring, but did not assess the resident in person or via telehealth. The LPN caring for the resident did not advocate for hospital transfer, relying on the provider's judgment, and was unsure if the PA knew the fall was unwitnessed. The provider later stated that, had he been aware of the full clinical picture, he would have considered a virtual assessment and possible hospital transfer. It was only after the Assistant Director of Nursing reviewed the communication and recognized the significant change in condition that the resident was sent to the hospital, where a significant intracranial hemorrhage was diagnosed. Interviews with staff revealed gaps in assessment, communication, and escalation of care following the unwitnessed fall, resulting in a delay in identifying and treating the resident's acute change in condition.
Failure to Provide Adequate Supervision and Update Care Plans After Falls
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls and injuries for multiple residents, as well as to implement and revise care plan interventions following falls. One resident with a history of falls, dementia, and moderate cognitive impairment experienced multiple unwitnessed falls, including one resulting in a multicompartmental acute intracranial hemorrhage. The care plan for this resident included broad interventions such as keeping the bed in a low position and offering frequent toileting, but these were not specific or descriptive enough for staff to follow. Staff interviews revealed a lack of clarity regarding the frequency of checks and toileting, and staff were unable to report when the resident was last assisted or checked. After falls occurred, no new interventions were added to the care plan, and the interdisciplinary team did not meet to review or revise interventions. The Director of Nursing and Nursing Home Administrator confirmed that care plan interventions were too broad and that post-fall reviews and care plan updates did not occur as required by facility policy. Another resident with Alzheimer's disease, repeated falls, and impaired mobility also experienced multiple unwitnessed falls, including incidents resulting in T3 and T8 vertebral fractures. The care plan for this resident was not updated after each fall, and immediate interventions to ensure safety were not implemented. Staff documentation and interviews indicated that the resident frequently attempted to self-transfer, did not consistently use assistive devices, and was not provided with interventions such as frequent rounding, signage, or reminders to use a walker. The care plan lacked specific interventions such as non-slip socks or a fall mat, despite these being used at times. The Director of Nursing acknowledged that interventions were not developed following each fall, and that immediate interventions should have been created to minimize risk. A third resident with a history of joint replacement and falls reported that staff did not provide the required assistance with transfers and toileting, despite being care planned as a one-person assist. The resident described being told by a CNA to be independent and was left to struggle without help, raising concerns for her safety. The Director of Therapy and Director of Nursing confirmed that the expectation was for staff to provide support or supervision for transfers and ambulation, especially for a resident with recent joint surgery. The facility's failure to provide adequate supervision, update care plans, and implement individualized interventions after falls contributed to the risk of further accidents and injuries.
Failure to Promote Resident Dignity and Provide Required Assistance
Penalty
Summary
A deficiency was identified when a resident with a history of right hip replacement, muscle weakness, difficulty walking, necrosis of the bone, and a history of falls requested assistance from a CNA to use the restroom. The resident's care plan specified the need for one-person assistance with a four-wheeled walker for locomotion, toilet use, and transfers. Despite this, when the resident called for help, the CNA told her she needed to learn to be independent and stood by without providing the requested assistance, even as the resident struggled to ambulate and expressed being in pain and concerned for her safety. The resident reported feeling that the CNA's response was condescending and demeaning, and that she was left to struggle without the necessary support, which caused her frustration and disappointment. The facility administrator confirmed that there had been no communication or customer service training for staff in the past twelve months. The incident was substantiated through interviews and record review, demonstrating a failure to provide an environment that promoted resident dignity and respect as required.
Failure to Resolve Resident Grievances and Follow Grievance Policy
Penalty
Summary
The facility failed to resolve a resident's concerns and did not follow its grievance policy, resulting in unresolved issues and the resident feeling frustrated and neglected. The resident, who had a diagnosis of depression, reported multiple ongoing concerns including inadequate accommodation of a vegetarian diet, lack of access to dental and podiatry care, issues with CPAP cleaning, inconsistent medication administration, missed therapy interventions, inconsistent wound care, missed bed baths, and delays in MRI scheduling. These concerns were discussed in a care conference and communicated to facility leadership, but the resident reported no updates or resolutions. Interviews with staff revealed a lack of awareness and understanding of the facility's grievance process. Several staff members, including CNAs and LPNs, were unable to describe the process for handling resident grievances or completing grievance forms. The resident reported never having a grievance form completed with her and was unaware of the facility's grievance process. The Director of Nursing and Social Worker were also unaware of the status of the resident's concerns or their own responsibilities in addressing them. The Nursing Home Administrator (NHA) was identified as the Grievance Officer per facility policy but was unable to provide updates on the resident's concerns and stated she was not responsible for following up on grievances. Only one grievance form was found, despite multiple concerns being raised. The facility's policy required the administrator to oversee the grievance process, receive and track concerns, and issue written decisions, but these steps were not followed for the resident's grievances.
Failure to Immediately Report Allegation of Abuse to Abuse Coordinator
Penalty
Summary
The facility failed to implement its policy and procedures regarding abuse and neglect when staff did not immediately report an allegation of abuse to the abuse coordinator. Specifically, a certified nursing assistant (CNA) witnessed a resident entering another resident's room and touching her breast area while she was calling out for help. The CNA reported the incident to an LPN, who redirected the resident and documented the event in a progress note, but did not immediately notify the abuse coordinator or administrator as required by facility policy. The incident was later reported to the state agency several hours after it occurred. Interviews with multiple staff members confirmed that they were aware of the requirement to report allegations of abuse immediately to the abuse coordinator, who was identified as the nursing home administrator. However, the LPN involved stated that they were unaware of the policy to report to the administrator and only documented the incident in the resident's record. The failure to follow the established reporting protocol resulted in a delay in notifying the appropriate personnel and authorities about the abuse allegation.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and neglect involving four residents. In one case, a resident with a history of falls was found on the bathroom floor with an abrasion and later diagnosed with a hemorrhage. The investigation file lacked critical components such as resident outcomes, documentation of family or agency notification, staff interviews, hospital record reviews, and a conclusion or corrective actions. The administrator was unable to provide details about the incident, the investigation process, or any measures taken to prevent recurrence. In another incident, a resident was observed touching another resident inappropriately. The investigation file included some documentation, such as staff statements and a five-day follow-up report, but did not contain assessments by physicians or social workers, evidence of ensuring the victim's sense of safety, or analysis of the root cause. Staff interviews revealed a history of inappropriate behavior by the alleged perpetrator and concerns about the adequacy of supervision and the thoroughness of investigations. The administrator could not provide documentation of assessments or daily safety checks and was unable to explain the investigation process or preventive measures. A third case involved a resident alleging rough care by a CNA. The investigation included interviews with other residents, some of whom reported negative experiences with the CNA. However, the investigation file did not include relevant clinical records, care plans, or documentation of follow-up interviews. The resident who made the allegation reported that the administrator did not complete the interview and that no staff followed up with her. The administrator was unable to provide documentation of additional interviews or evidence of care plan updates. The facility's abuse policy requires thorough and objective investigations, but the documentation and actions taken did not meet these standards.
Failure to Consistently Implement Pressure Ulcer Prevention Measures
Penalty
Summary
A male resident with diagnoses including mild cognitive impairment, Alzheimer's disease, dementia, weakness, and pain was identified as being at risk for pressure ulcers due to decreased mobility, friction, and overall decline. The resident had a history of a Stage 3 pressure ulcer on the left heel, which had previously resolved, but remained at high risk for skin breakdown. The care plan included interventions such as applying skin prep to the left heel, floating heels while in bed, encouraging the use of heel boots, frequent turning and repositioning, and monitoring for skin changes. Despite these interventions, multiple observations revealed that the resident was not consistently provided with pressure-reducing devices. On several occasions, the resident was found in bed without heel boots or pillows to elevate his heels, and his feet were observed resting on the footboard of a bed that appeared too small for his height. Staff interviews confirmed that the resident often removed his boots and that alternative offloading methods, such as pillows, were not always implemented. The resident was also noted to slide down in bed, requiring frequent repositioning, and staff acknowledged the need for a bed extender due to his height, but this had not yet been addressed at the time of the observations. As a result of these lapses, a new area of redness and open skin was observed on the resident's left heel, indicating the development of a new facility-acquired pressure ulcer. Staff recognized the issue during the survey and took steps to report and address the wound, but the deficiency was identified due to the failure to consistently implement pressure ulcer prevention interventions as outlined in the resident's care plan.
Widespread Neglect and Abuse Due to Staffing Failures and Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from neglect and abuse, resulting in multiple incidents where residents did not receive necessary care and supervision. On several occasions, licensed nursing staff did not accept responsibility for the care and supervision of residents on specific halls, leading to widespread missed medications, significant medication errors, and a lack of overall supervision. For example, on multiple dates, nearly all residents on the 300 and 400 Halls missed their scheduled medications, including critical medications for conditions such as seizures, diabetes, hypertension, and heart disease. Interviews with staff revealed that staffing shortages, lack of communication, and management inaction contributed to these failures. Staff reported being left alone to care for large numbers of residents, not receiving proper shift handoffs, and being unable to contact management for assistance. Residents expressed anxiety and concern over missed medications, with one resident attempting to elope from the facility during a period of inadequate supervision. In addition to neglect, the facility failed to protect residents from physical and verbal abuse. One incident involved a CNA physically and verbally abusing a severely cognitively impaired resident during personal care. Witnesses reported that the CNA struck the resident multiple times with an open hand, twisted the resident's arm, and exchanged verbal insults with the resident. The abuse was witnessed by other staff, who reported the incident to management. The resident sustained redness to the left shoulder and arm, and a care plan was developed following the incident to address the trauma experienced by the resident. There were also incidents of resident-to-resident physical abuse, where one resident physically assaulted two other residents on separate occasions. These events were documented and reported by the facility. The report includes detailed accounts from staff interviews, medication administration records, and witness statements, all of which confirm the occurrence of neglect and abuse due to inadequate staffing, lack of supervision, and failure to follow established policies and procedures.
Removal Plan
- Staff involved in the incidents were disciplined including termination.
- All missed medications were addressed with physician orders reviewed and implemented. Families and responsible parties were notified of the incidents and corrective actions taken. Morning meetings now include reviews of missed medications for immediate investigation and follow-up. Medication errors are documented, with physicians, residents, and responsible parties notified.
- Facility policies on Medication Administration and Controlled Medication Guidelines were reviewed and all licensed nurses were re-educated. All licensed nursing staff received additional and/or re-education on Medication Administration and Error Prevention and Reporting Shortages and Advocating for Residents. Additional in-service education provided to all nursing and CNA staff.
- Nursing leadership on-call with an identified cell phone for staff to call if needed for any reason. Nursing remains on-call 24/7. An additional process was added for calling at the start of each shift to ensure all scheduled staff have arrived.
- In situations where coverage is needed, the on-call staff will prioritize ensuring clinical supervision and assistance with medication pass. Management staff to review the current staffing matrix and identify available resources including but not limited to agency use through contracted vendors, PRN staff and current staff working overtime. Identify on-call staff to come in as well as beginning to cross-train existing personnel to cover immediate needs.
- DON/Designee and Administrator will meet daily to discuss any calls from the previous day/night to ensure continuity of care throughout all departments and ensuring all needs have been met.
Failure to Protect Resident from Staff Abuse and Immediate Removal
Penalty
Summary
The facility failed to implement its abuse policy and did not respond immediately to protect a resident from staff-to-resident abuse. During a bed bath, a CNA was observed by two other CNAs to have engaged in a physical altercation with a resident, which included hitting the resident multiple times with substantial force and exchanging verbal insults. The incident escalated to the point where the resident and the CNA were hitting each other back and forth, with witness statements estimating the resident was struck between 10 and 20 times. The resident involved was a female with severe cognitive impairment, as indicated by a BIMS score of 3, and had a history of traumatic events related to physical assault. Despite witnessing the abuse, the two CNAs present did not intervene to stop the incident or protect the resident. Both reported feeling shocked and unsure of how to respond, with one expressing fear of potential escalation if they intervened. Instead of intervening, the CNAs left the room, leaving the resident alone with the alleged abuser, and only reported the incident after leaving the scene. The abuse continued after their departure, as indicated by continued yelling and slapping heard from the hallway. The facility's abuse policy required immediate reporting of abuse and removal of the resident from contact with the alleged abuser to ensure protection from harm. However, these procedures were not followed during the incident. The failure to act promptly and remove the resident from the situation resulted in continued physical and verbal abuse, contrary to the facility's stated policies and procedures for resident protection.
Latest citations in Michigan
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
