Optalis Health And Rehabilitation Of Kingsford
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsford, Michigan.
- Location
- 1225 Woodward Avenue, Kingsford, Michigan 49801
- CMS Provider Number
- 235267
- Inspections on file
- 33
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Kingsford during CMS and state inspections, most recent first.
A resident with neurogenic bladder, paraplegia, a Stage 4 sacral pressure ulcer, and an indwelling Foley catheter was not monitored for urinary output despite dependence on staff for care and a history of UTI, hydronephrosis, and recent nephrostomy tube removal. CNA documentation over several months only coded bladder status as "continence not rated due to indwelling catheter" without recording catheter patency or urine amounts, and the MAR/TAR contained no measured outputs even after catheter changes and irrigations. The resident later experienced hematuria and repeated catheter problems, including leakage, blood in urine, and lack of drainage, culminating in being found soaked in blood with an empty drainage bag and subsequent transfer to the hospital for UTI and anemia. The DON acknowledged that urine output was not routinely measured for catheterized residents unless specifically ordered by a physician, and no such order or measurements were present in the record, contrary to the facility’s catheter monitoring policy and referenced professional standards regarding urine output assessment.
A resident with severe cognitive impairment exited the facility without staff knowledge and entered a nearby business. Staff were alerted and retrieved the resident, but the wander guard device did not alarm at the exit. After the incident, no new interventions were added to the care plan, contrary to facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
Surveyors found that food items such as cubed cheeses and summer sausage were stored in the main dining room refrigerator without required labels, open dates, or use-by dates, and that storage areas and containers were soiled and unsanitary. An Activity Director reported not knowing about labeling requirements for food used in activities, and facility policy mandates were not followed, resulting in improper food storage and increased risk of cross-contamination.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident was found to be self-administering medications, including acetaminophen and laxatives, without an assessment, physician order, or care plan in place. The medications were kept unsecured in the resident's purse, and nursing staff were unaware of their presence. Facility policy requires an IDT assessment, physician order, care plan documentation, and secure storage for self-administered medications, none of which were followed in this case.
Three residents who were transferred to the hospital did not receive written notification of the bed hold policy, as required by facility policy. Medical records lacked documentation that the bed hold policy was provided to the residents or their representatives during any of their hospital transfers, despite multiple occurrences.
A resident with cognitive impairment and physical limitations was found with visibly soiled hands and encrusted fingernails, despite requiring moderate assistance with personal hygiene. Documentation did not reflect any hand or nail care provided, nor any refusals of such care, and staff were unaware of the resident's condition until it was pointed out. Facility policy required assistance with grooming and hygiene for dependent residents, but this was not provided in this case.
A resident with multiple chronic conditions was found to have an IV site with an undated dressing, and staff could not confirm when it was last changed. Documentation of the IV placement was incomplete, lacking details such as catheter size and resident comfort. Additionally, there was no physician order to change the IV site every 72 hours, contrary to facility policy and standard practice.
A resident with respiratory failure and other conditions was found using a nasal cannula with an empty, undated humidifier and a nebulizer left with condensation and medication residue on their bed and bedside table. Staff interviews and observations confirmed that respiratory equipment was not cleaned, dried, or stored according to facility policy, and humidifiers were not dated or replaced as required.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with intact cognition and multiple diagnoses was found with vitamin gummies left at the bedside without a physician order or completed self-administration assessment. An LPN acknowledged that medications had been left unsupervised and that observation of administration had not previously occurred, leading to a deficiency due to lack of required authorization and assessment.
A resident with intact cognition and multiple medical conditions reported several missing personal items, including jewelry and clothing, over a period of months. Despite submitting multiple written grievances, the facility did not promptly locate or replace the items, and documentation of resolution and resident satisfaction was incomplete. Required inventory procedures were not followed at admission, and the facility's policy for timely investigation and resolution was not met.
A resident's urinary nephrostomy drainage bag was found hanging into a garbage can without a dignity cover, despite care plan interventions requiring proper maintenance and use of a cover. The resident, who has a history of frequent UTIs, confirmed the bag should not be in the garbage, and facility staff acknowledged the infection control issue.
Chronic understaffing led to multiple residents being left wet, soiled, and without adequate grooming or oral care. Staff and family interviews, as well as direct observations, confirmed that care was frequently delayed or omitted due to insufficient CNA and nursing coverage, with agency staff often failing to show up. Residents with significant ADL needs were particularly affected, and concerns about incomplete care were repeatedly raised in resident meetings.
Two residents with significant physical and cognitive impairments did not receive necessary assistance with activities of daily living, including hygiene, grooming, and toileting. Both were observed with poor personal hygiene and, in one case, left wet and soiled for an extended period. Staff and resident interviews attributed these deficiencies to ongoing staffing shortages and unreliable agency staff, resulting in missed or delayed care.
A facility failed to maintain the accuracy and confidentiality of resident records, resulting in incorrect information being sent with a deceased resident's remains to a funeral home. The error involved two residents and was identified by the funeral home, which contacted the facility for clarification. The mistake was attributed to a failure to verify the deceased's identity and cross-check documentation, with two staff members involved in printing the paperwork but no clear verification process in place.
A resident with a penile tear due to chronic catheter use did not receive consistent wound assessments, as required by facility policy. Despite being prescribed lidocaine for pain, there was no documentation of routine evaluations to monitor the wound's healing or identify worsening conditions. The DON could not find any records of wound evaluations, and an LPN was unsure about assessment frequency.
A resident with Parkinson's Disease and severe cognitive impairment, requiring substantial assistance, developed a Stage 3 sacral pressure injury due to the facility's failure to conduct consistent skin assessments. Despite being at high risk, the facility did not perform regular assessments as per policy, leading to unidentified wounds and delayed treatment. The DON confirmed a lack of documentation and assessment, increasing the risk of miscommunication regarding the resident's needs.
The facility failed to provide proper catheter care for two residents, resulting in a urinary collection bag touching the floor and a drainage leg bag being overfilled. A resident's catheter bag was observed without a securement device, risking dislodgement and infection. Another resident's leg bag was not emptied as per policy, causing urine backup. The facility's policies on catheter care were not followed, as confirmed by the DON.
A resident with a history of heart failure and recent cardiac surgery experienced severe respiratory distress and fluid volume overload due to the facility's failure to timely obtain and process physician orders for respiratory assessment and diagnostics. Despite the resident's complaints and a nurse practitioner's order for a chest x-ray, the test was not performed, leading to the resident's hospitalization.
A resident experienced a fall and knee pain due to the inappropriate use of a sit-to-stand mechanical lift instead of the required total mechanical lift. The resident's care plan specified the need for a total mechanical lift with two-person assistance, but CNA staff mistakenly believed the transfer method had been changed. The Therapy Director confirmed the resident was not approved for the sit-to-stand lift. No audits were conducted post-incident to ensure compliance with care plans.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices and an open wound. A CNA provided care without wearing a protective gown, contrary to the resident's care plan and physician orders. The CNA was unaware of the EBP requirement due to a lack of signage or PPE cart, leading to potential infection spread.
A resident with multiple health conditions did not receive breakfast due to a lack of assistance and a system to ensure meal delivery. Despite needing help with eating, the resident's meal was not brought to him, and dietary staff noted frequent returns of untouched trays without proper documentation.
A resident with Parkinson's Disease experienced delays in receiving critical medication due to the facility's failure to provide timely pharmaceutical services. The resident reported not receiving Amantadine HCl as scheduled, with the first dose significantly delayed on the day of admission. The facility did not notify the physician or pharmacist about the medication's unavailability, contrary to their pharmacy policy.
A facility failed to inform a resident's representative of the grievance policy and did not address all grievances promptly. Despite numerous emails from the representative about care concerns, many were not documented in the grievance log, leading to delays or omissions in responses. The resident had severe cognitive impairment and required specific incontinence care, which was not consistently provided.
A resident with severe cognitive impairment and a history of traumatic brain injury experienced inadequate grooming, dressing, personal hygiene, and toileting due to the facility's failure to adhere to their care plan. The resident was often found in soiled clothing without necessary incontinence briefs, and staff failed to provide consistent assistance with personal hygiene. Interviews confirmed these deficiencies, with staff acknowledging inappropriate handling of the resident's care.
The facility failed to implement a comprehensive wound care program, resulting in the development and worsening of multiple pressure injuries among residents. Observations revealed inadequate wound care techniques, improper use of heel protection, and insufficient documentation and care planning, leading to significant lapses in wound care management.
The facility failed to provide adequate nursing staff, resulting in extended call light wait times and insufficient care. Residents reported delays in receiving assistance with ADLs, with call light logs showing multiple instances of wait times exceeding 15 minutes, and in some cases, over an hour. These issues were particularly prevalent between 5:00 PM and 7:00 AM, as confirmed by resident council members.
The facility failed to ensure the dietary department was staffed with sufficient and properly trained personnel. The Kitchen Manager had not completed the Certified Dietary Manager's course and lacked credentials in food service sanitation. The Registered Dietitian's responsibilities were limited to clinical assessments, with no involvement in kitchen functions. The corporate registered dietitian consulted via phone but had not visited the facility to assist in training.
The facility failed to ensure that menus met the nutritional needs of residents, were followed according to recipes, and were reviewed and approved by a Registered Dietitian. A resident with a healing amputation expressed concerns about inadequate protein in meals, and observations confirmed insufficient protein content in the Mostaccioli dish served. Dietary staff admitted to not following recipes accurately, leading to potential nutritional deficiencies for all 73 residents.
The facility failed to follow menu recipes, resulting in a Mostaccioli dish being served with insufficient cottage cheese. The cook admitted to using only two and a half pounds of cottage cheese instead of the required five pounds for 50 servings. The kitchen manager confirmed that the facility did not maintain records to verify if recipes were followed correctly, potentially leading to nutritional deficiencies for all 73 residents.
A resident with a physician's order for a cardiac diet received inappropriate food items due to the facility's dietary software limitations and lack of a diet manual. The Dietary Manager and Corporate Dietitian were unaware of the differences between diet types, leading to non-compliance with the prescribed diet.
The facility failed to maintain proper food safety and sanitation standards, including improper temperature monitoring of hot food, inadequate dishwashing practices, and unsafe storage of food service items. These deficiencies pose a risk of foodborne illness to the residents.
The facility failed to manage pressure ulcers effectively and provide adequate leadership support during increased staffing needs. The NHA and DON could not provide evidence of QAPI committee activities or data analysis for pressure ulcers. The DON was reported to be under the influence of alcohol and unavailable for emergencies, and the facility lacked an on-call policy for supervision and nursing staff.
The facility failed to conduct and document an annual facility-wide assessment, resulting in the potential for inadequate knowledge of the facility population's needs and resources to care for the 73 residents. The provided Facility Assessment was outdated and reflected previous ownership. The NHA and Regional Clinical Resource nurse were waiting for updated CMS guidelines before updating the assessment.
The facility failed to maintain an effective QAPI program to address and correct deficiencies in the prevention and treatment of pressure ulcers. The QAPI committee did not document performance improvement activities, and the DON could not provide data on pressure ulcer tracking or trending. Weekly meetings to discuss pressure injuries had ceased, leading to a system failure in the skin and wound program.
The facility's QAPI committee failed to meet composition and attendance requirements, with missing sign-in sheets, absent Medical Director, and lack of direct care staff participation, risking ineffective care coordination for 73 residents.
The facility failed to maintain essential kitchen equipment, leading to water overflow from a three-compartment sink and an overheated dish machine. Despite ongoing issues and multiple service attempts, the equipment remained unrepaired, posing potential risks to staff and residents.
The facility failed to follow through with the grievance process initiated by resident representatives and the resident council. Grievances about resident care and the lack of evening snacks were not addressed, and some grievance forms were found in the trash without follow-up. The facility did not adhere to its policy on Investigations of Grievances, resulting in unresolved grievances and a lack of communication with complainants.
The facility failed to provide mandatory QAPI training to four out of seven staff members reviewed. Interviews revealed a lack of awareness and understanding of the facility's quality improvement projects and goals. The facility's policy on Quality Assessment and Process Improvement was outdated and not effectively implemented.
The facility failed to ensure proper care of indwelling urinary catheter equipment for a resident, leading to potential contamination and infection risk. Observations revealed catheter tubing resting on the floor and improper handling of the drainage bag, including failure to disinfect the spout after emptying urine. Both CNAs and the Nurse Manager acknowledged the importance of keeping catheter equipment off the floor and disinfecting the spout to prevent infection.
The facility failed to assess the respiratory status of a resident with COPD and chronic respiratory failure who was receiving as-needed respiratory medications and supplemental oxygen. Despite multiple administrations of respiratory medications, no respiratory assessments or oxygen saturation levels were documented after the initial assessment. The resident's care plan also lacked focus areas and interventions related to their respiratory conditions.
A facility failed to properly administer and document an insulin dose for a resident. An RN administered an incorrect dose of insulin and documented it as the full dose in the MAR. The DON was unaware of the incident, and there was no documentation or physician notification in the EMR.
The facility failed to maintain a medication error rate of 5% or less, resulting in an 8.57% error rate. A nurse administered incorrect doses of Keppra and did not follow proper insulin administration guidelines, as confirmed by facility policies and interviews.
Failure to Monitor and Document Urinary Output for Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document urinary output for a resident with an indwelling urinary catheter. The resident had multiple significant diagnoses, including neurogenic bladder, diabetes, paraplegia, and a Stage 4 sacral pressure ulcer, and was dependent on staff for toileting hygiene, bed mobility, and transfers. The MDS documented the presence of an indwelling urinary catheter, and the MAR/TAR included an order to maintain the Foley catheter and provide care every shift for urinary retention beginning in late October 2025. Despite this, the EMR contained no documented measured amounts of urine output from the catheter over the review period. From late October through mid-December 2025, CNA point-of-care documentation consistently coded the resident as "3 - Continence not rated due to indwelling catheter" under bladder elimination, with no entries describing catheter patency or the amount and character of urine output. There was also no documentation of measured urine output after the nephrostomy tube was clamped and then removed by urology on 10/27/2025, even though the urology note indicated uncertainty about how much had been draining from the nephrostomy tube and referenced prior sepsis and hydronephrosis. The facility’s own catheter use policy required ongoing monitoring for changes in condition related to potential catheter-associated UTIs, including recognizing, reporting, and addressing such changes, but the record lacked objective urine output measurements. Progress notes show that the resident had a recent history of UTI requiring six weeks of cefepime and vancomycin, and later developed moderate to severe hematuria. On 12/16/2025, staff documented multiple issues with the catheter, including urine leaking around the catheter, blood mixed with urine, lack of patency, and repeated need for flushing. That afternoon, the resident was found soaked in blood from the catheter insertion site with no urine in the drainage bag, prompting transfer to the ED. Subsequent documentation indicated the resident was hospitalized with heart rhythm issues, UTI treated with antibiotics, and anemia requiring blood transfusions. Interviews with the DON revealed inconsistent statements about whether urinary output for catheterized residents should be measured routinely, and the DON ultimately stated that output was only measured when ordered by a physician, even for residents with a history of UTI and hydronephrosis and recent nephrostomy tube removal. No physician order for urine output measurement was obtained, and no such measurements were documented.
Failure to Update Care Plan and Supervision After Resident Elopement
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and diagnoses including anxiety disorder, depression, and non-Alzheimer's dementia, was admitted to the facility. The resident was able to leave the facility unattended, as observed by the Admissions Director, who saw the resident exiting the building with visitors and subsequently entering a nearby business. Staff were alerted via two-way radio, and a registered nurse located the resident at the business and accompanied him. The resident's wander guard device did not alarm at the facility entrance, which was the point of exit. Following the elopement, there was no evidence that the resident's care plan was updated with new interventions to address the incident, despite facility policy requiring such updates after an elopement. Multiple staff interviews confirmed that no new interventions were added to the care plan after the event. The facility's policy on elopement, which includes updating the care plan and interventions after a resident is located, was not followed in this instance.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Improper Food Storage, Labeling, and Sanitation in Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's main dining room. An individual cup of brown sugar was found uncovered and exposed to air in a cabinet drawer containing various condiments, with the drawer itself soiled by food crumbs and sticky substances. A storage container of popcorn kernels was discovered in a cupboard above the refrigerator; the container was yellowing, sticky, greasy, and lacked any date or label. In the refrigerator, several packages of cubed cheeses and summer sausage were present without any labels, open dates, or use-by dates. A gallon-sized bag of sliced summer sausage, approximately half full and appearing dried out, was also found without any identifying information. These food items had been used for a recent event and were not properly labeled or dated as required by facility policy. Interviews revealed that the Activity Director was unaware of the requirement to label and date food items ordered through the kitchen for activities. A review of the facility's Food and Nutrition Services policy confirmed that all food removed from original packaging must be labeled with arrival and open dates, and that leftover foods must be labeled, dated, and either frozen or discarded within 72 hours if refrigerated. The observed practices did not comply with these policies, resulting in improper food storage, inadequate labeling, and unsanitary conditions that could contribute to cross-contamination and foodborne illness.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Authorize Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering medications, including acetaminophen, a stool softener, and a laxative, without an appropriate assessment or physician order authorizing self-administration. The resident reported taking acetaminophen every four hours for pain related to a recent shingles episode and kept these medications in her purse, which had been brought in by her daughter. The resident demonstrated knowledge of her medication regimen and showed the surveyor the medications in her possession. However, there was no documentation of an assessment for self-administration, no physician order permitting this practice, and the medications were not stored in a secure location as required by facility policy. Interviews with nursing staff confirmed they were unaware the resident had medications in her room and that no assessment or care plan for self-administration had been completed. Review of the resident's physician orders and medication administration record showed an order for acetaminophen with specific dosing instructions, but the resident was self-administering a different strength and frequency than ordered. Facility policy requires an interdisciplinary team assessment, physician order, care plan documentation, and secure storage for self-administered medications, none of which were in place for this resident.
Failure to Provide Written Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to three residents who were transferred to the hospital. Specifically, interviews and medical record reviews revealed that these residents had multiple hospital transfers during their stays, but there was no documentation indicating that either the residents or their responsible parties received the required written notice of the bed hold policy at the time of transfer. The facility's own policy states that the Admissions Director or designee is responsible for sending the bed hold policy and transfer notice to the resident's representative when a resident is admitted to the hospital. For each of the three residents reviewed, the medical records did not contain evidence that the bed hold policy, including the duration of the bed hold, was provided during any of their hospital transfers. The residents themselves were unsure of the exact dates of their hospitalizations, but confirmed that they had been transferred out to the hospital on more than one occasion. The lack of documentation and notification was consistent across all reviewed cases, indicating a failure to follow the facility's established procedures for informing residents and their representatives about bed hold policies during hospital transfers.
Failure to Provide Hand and Nail Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with metabolic encephalopathy, liver cancer, muscle weakness, and moderate cognitive impairment was observed with visibly soiled hands and brown-colored substance encrusted under the fingernails of both hands. The resident required moderate assistance with personal hygiene and was frequently incontinent of bowel and bladder. The care plan and Kardex specified that nail care should be provided on bath days and as necessary, but there was no documentation in the electronic medical record (EMR) or progress notes regarding fingernail or hand hygiene. The resident's care plan also indicated a need for one-person staff assistance with personal hygiene, and there was no documentation of the resident refusing care related to hand or fingernail hygiene. During interviews, the resident reported not receiving help with hand hygiene, and a CNA confirmed that while the resident sometimes refused care, there was no recollection of refusals related to hand and fingernail hygiene. The CNA was unaware of the resident's soiled hands and nails until prompted and acknowledged that the hands and fingernails would be cleaned immediately. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and personal hygiene, but this was not followed in this instance.
Failure to Document and Maintain IV Site per Standards of Practice
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including diabetes mellitus, dementia, urinary tract infection with an indwelling catheter, and heart failure, was observed to have an intravenous (IV) site in the left forearm with a dressing that was not dated. During a medication pass, staff could not determine how long the IV site had been in place due to the missing date, and the responsible LPN acknowledged that the site should be replaced if undated. Review of the resident's electronic medical record showed that the documentation of the IV placement lacked details such as the size of the catheter, number of attempts, and the resident's comfort during the procedure. Further review of the resident's physician orders for the relevant month revealed there was no order to change the IV site every 72 hours, as required by standards of practice. The facility's policy on catheter insertion and care indicated that administration sets and tubing should be changed at specific intervals to prevent infection, but this was not reflected in the resident's care. The Nursing Home Administrator confirmed that the expectation was for IV dressings to be dated and sites to be changed every 72 hours or sooner if indicated, but this was not followed in this instance.
Failure to Maintain and Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a sanitary manner for a resident with multiple diagnoses, including dementia, respiratory failure, depression, and heart failure. Observations revealed that the resident was using a nasal cannula connected to an oxygen concentrator with a humidifier that was empty and not dated. Additionally, a nebulizer with visible condensation and residual medication was found lying on the resident's bed and bedside table during multiple observations. The resident reported that staff only added medication to the nebulizer and turned it on, without rinsing it out after use. The resident also mentioned experiencing a bloody nose, possibly related to the empty humidifier. Interviews with nursing staff indicated that humidifiers were replaced weekly, but there was no evidence that the humidifier in use was dated or replaced as required. Facility policy required daily checks and weekly replacement of humidifiers, as well as rinsing and air-drying nebulizers after each use, with proper storage. However, the observed practices did not align with these policies, as the equipment was not cleaned, dried, or stored appropriately, and humidifiers were not dated or maintained according to protocol.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Ensure Proper Authorization for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple diagnoses including cancer, neurogenic bladder, anxiety disorder, depression, and an unspecified mood disorder, was observed with a cup of vitamin gummies left at the bedside. The resident reported to an LPN that the number of gummies was inconsistent with what was expected, and the LPN acknowledged that she had not previously observed the resident taking the gummies. The LPN then stayed to observe the resident consume the gummies, which prompted the resident to question why observation was necessary, as it had not been done before. Further investigation revealed that there was no physician order in place for the resident to self-administer medication, nor had a Self-Administration of Medication Assessment been completed prior to the incident. The facility's staff confirmed that medications had been left at the bedside without the required physician order or assessment, and that these were only implemented after the surveyor's observation. The deficiency was identified due to the lack of proper authorization and assessment for self-administration of medication, resulting in unsupervised medication being left at the resident's bedside.
Failure to Promptly Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly resolve grievances for a resident who reported multiple missing personal items, including valuable jewelry, clothing, and sentimental belongings. The resident, who was cognitively intact and had a history of cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder, reported the loss of these items over a period of months. Despite submitting at least three written complaints and concern forms, the facility did not locate or replace the missing items in a timely manner. Documentation showed that the resident was instructed to select replacement items, but there was no evidence that the process was completed or that the resident was notified of a resolution or expressed satisfaction with the outcome. Review of facility records revealed that the required Personal Effect Inventory was not completed at the time of the resident's admission, but only after multiple complaints had been filed. The facility's policy required that missing items be investigated and resolved within two weeks, but this was not adhered to in the resident's case. Interviews with staff and the Nursing Home Administrator confirmed that the process for investigating and resolving grievances was not consistently followed, and key documentation regarding resolution and resident satisfaction was missing.
Improper Maintenance of Nephrostomy Drainage Bag Leading to Infection Control Concern
Penalty
Summary
A urinary nephrostomy drainage bag for one resident was observed clipped to the bed linen, with the bag hanging down into the resident's garbage can, which contained various garbage items. The drainage bag did not have a privacy or dignity cover, and the weight of the urine caused the bag to lower further into the garbage. When questioned, the resident confirmed that the bag should not be in the garbage can and reported a history of frequent urinary tract infections, including a recent severe episode requiring IV antibiotics. The resident's care plan included interventions to be mindful of the nephrostomy tubes, ensure they are fully closed after flushing, and provide a collection bag cover at all times. Despite these interventions, the drainage bag was not properly maintained, resulting in direct contact with contaminated surfaces. Facility staff, including the Nursing Home Administrator and Assistant Director of Nursing, acknowledged the infection control concern when made aware of the situation.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents, resulting in multiple instances where care was not delivered in a timely or adequate manner. Several staff members, including RNs, LPNs, and CNAs, reported chronic understaffing, frequent agency staff no-shows, and the need to prioritize essential care over routine grooming and hygiene. Observations and interviews revealed that residents were left wet and soiled for extended periods, did not receive regular oral care or grooming, and were often disheveled. Staff described being unable to keep up with documentation, emergencies, and admissions due to being pulled in multiple directions and covering for absent colleagues. Specific residents were directly affected by these staffing shortages. One resident, who required two-person assistance for toileting and ADLs due to hemiplegia following a stroke, was found multiple times in soiled clothing and bedding, with visible signs of neglect such as unbrushed hair, dirty fingernails, and dried substances around the mouth. Another resident with severe cognitive impairment and a history of stroke was observed with poor oral hygiene, including dried saliva and food buildup, and was not consistently provided with necessary assistance. A third resident, also with hemiplegia, reported waiting over an hour for help, experiencing catheter leaks, and not receiving regular denture care or showers. These residents did not have a documented history of refusing care, indicating the deficiencies were due to staffing issues rather than resident choice. Additional evidence of the deficiency included observations of residents waiting extended periods for meals and drinks in the dining room, family members stepping in to provide basic care, and repeated concerns raised in Resident Council meetings about inadequate staffing and incomplete care. Facility records confirmed numerous open CNA and nursing positions across all shifts, with reliance on agency staff who frequently failed to report for duty. The facility's own staffing policy emphasized the need for appropriate staffing at all times, yet the documented events and staff interviews demonstrated a consistent failure to meet this standard, directly impacting resident care and dignity.
Failure to Provide Timely and Adequate ADL Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with a history of stroke and hemiplegia, reported significant delays in receiving help to get out of bed, having their catheter emptied, and assistance with personal hygiene such as denture care and nail trimming. Observations confirmed that this resident's fingernails were visibly soiled, and the resident stated it had been several days since proper oral care was provided. The resident also described witnessing other residents left unattended, uncleaned after meals, and not receiving scheduled showers, especially during periods of staff shortages and high reliance on agency staff. Another resident, also with a history of stroke and moderate cognitive impairment, was observed with poor hygiene, including soiled hands, chipped and dirty fingernails, unbrushed hair, and food particles on clothing. This resident was found by staff crying out for help after being left wet and cold in urine-soaked bedding and clothing, which had not been changed for an extended period. Staff interviews corroborated that the resident required assistance with all ADLs and that these needs were not consistently met due to staffing shortages. Staff also reported that many residents on the unit required two-person assistance, and that showers, nail care, and grooming were often missed or delayed. Multiple staff members, including CNAs, RNs, and a physical therapist, confirmed ongoing issues with inadequate staffing, particularly with agency staff not showing up or canceling shifts at the last minute. These staffing issues directly impacted the ability to provide timely and adequate ADL care, resulting in residents being left soiled, unkempt, and without proper hygiene. Facility policy required that residents unable to perform ADLs independently receive necessary assistance, but observations and interviews demonstrated that this standard was not consistently met for the residents involved.
Confidentiality Breach in Resident Records
Penalty
Summary
The facility failed to ensure the accuracy and confidentiality of resident records, resulting in the release of incorrect resident information accompanying a deceased resident's remains to the funeral home. Specifically, the body of Resident #6 was transferred to the funeral home with documentation that incorrectly identified the deceased as Resident #9. This included the face sheet with full name, date of birth, and medical history of Resident #9. The error was identified by the funeral home representative, who contacted the facility to clarify the discrepancies in the records provided. Interviews conducted revealed that the mistake occurred due to a failure to verify the identity of the deceased and cross-check documentation before releasing the body. The primary nurse was responsible for printing the information to accompany the resident to the funeral home, but it was noted that two staff members were involved in printing the paperwork. However, there was no verification of who double-checked the paperwork, leading to the error. The incident occurred in the middle of the night, which was suggested as a possible contributing factor to the mistake.
Inadequate Wound Assessment for Resident
Penalty
Summary
The facility failed to ensure appropriate and consistent assessment of a penile tear for a resident, resulting in the potential for unidentified worsening of the wound and delay in treatment. The resident, who had diagnoses including obstructive uropathy, benign prostatic hyperplasia, and dementia, was admitted to the facility and required substantial assistance for toileting hygiene and was dependent for showering and bathing. The resident was prescribed topical lidocaine for pain related to a slit on the head of his penis caused by chronic use of an indwelling urinary catheter. However, there was no documentation of routine wound evaluations, which are necessary to track healing progression or identify worsening conditions. During an interview, an LPN was unsure about the frequency of wound assessments, and the Director of Nursing was unable to find documentation of wound evaluations for the resident's penile tear. Observations revealed the resident had a penile tear through the dorsal aspect of the glans, and he reported pain at the wound site during the application of lidocaine cream. The facility's policy required weekly evaluations of skin alterations, but the electronic medical record did not contain any weekly evaluations of the resident's penile wound, including measurements, wound description, or signs and symptoms of infection.
Failure to Conduct Consistent Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to conduct consistent skin and risk assessments for a resident at risk for pressure injuries, leading to the potential for unidentified wounds and delayed treatment. The resident, who had Parkinson's Disease and severe cognitive impairment, required substantial assistance for movement and was dependent on staff for transfers. Despite being at high risk for pressure injuries, as indicated by the Minimum Data Set (MDS) assessment, the facility did not perform regular skin assessments as per their policy. The resident developed a new, in-house acquired Stage 3 sacral pressure injury, which was identified on 12/26/2024. The facility's policy required weekly skin assessments using the Braden Scale for the first four weeks after admission and then quarterly. However, there were no documented assessments from 12/09/2024 to 12/26/2024, and the Director of Nursing confirmed that a skin evaluation was signed off but not documented in the electronic medical record. This lack of documentation and assessment increased the risk of unidentified skin issues and miscommunication regarding the resident's needs. The facility's failure to adhere to its policy and professional standards of practice resulted in a deficiency citation.
Deficiency in Catheter Care and Management
Penalty
Summary
The facility failed to ensure proper care for residents with urinary catheters, as evidenced by observations and interviews. Resident #4 was found with a urinary catheter collection bag touching the floor without a barrier, and no securement device was in place to prevent catheter dislodgement or urethral trauma. Despite the care plan indicating the need for a securement device, none was observed, and the collection bag was improperly positioned, risking infection. Resident #2, who has obstructive uropathy, benign prostatic hyperplasia, and dementia, was observed with a urinary drainage leg bag that was completely full, causing urine to back up into the catheter tubing. The facility's policy requires drainage bags to be emptied when half to three-fourths full, but this was not adhered to, leading to potential discomfort and infection risk. The LPN acknowledged the need for more frequent emptying due to the resident's tendency to remove the catheter anchor device. The facility's policies on catheter care and securement were not followed, as evidenced by the observations of the residents' catheter management. The Director of Nursing confirmed the expectation for securement devices and proper bag placement, which were not met in these cases, highlighting a failure in adhering to professional standards of practice for catheter care.
Failure to Process Physician Orders Leads to Resident Hospitalization
Penalty
Summary
The facility failed to timely obtain and process physician orders for respiratory assessment, treatment, and radiology diagnostics for a resident, leading to severe respiratory distress and fluid volume overload. The resident, who had a history of heart failure, renal insufficiency, and recent cardiac surgery, was admitted without receiving a diuretic and had intact cognition. Despite the resident's complaints of worsening cough and fluid retention, a chest x-ray ordered by the nurse practitioner was not performed, and the resident's condition deteriorated over the weekend. The resident's progress notes indicated respiratory distress and a request for daily weight monitoring due to congestive heart failure, but these were not consistently documented or acted upon. The facility's failure to document and execute physician orders for a chest x-ray and daily weights contributed to the resident's decline. The resident experienced significant respiratory distress, with oxygen saturation dropping to critical levels, leading to hospitalization for respiratory distress, fluid volume overload, and COVID. Interviews with staff revealed miscommunication and a lack of follow-through on physician orders. The nurse practitioner and other staff failed to ensure the chest x-ray order was entered into the electronic medication administration record, leaving nursing and scheduling staff unaware of the need for the diagnostic test. Additionally, routine lung sound assessments were not conducted, and the resident's care plans were not updated to reflect necessary interventions until the day of the resident's transfer to the hospital.
Failure to Use Appropriate Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate use of a mechanical lift for a resident, resulting in a fall and subsequent knee pain. The resident, who was cognitively intact and dependent on staff for all transfers, was supposed to be transferred using a total mechanical lift as per her care plan. However, during an attempted transfer using a sit-to-stand mechanical lift, the resident's feet fell off the lift platform, causing her to fall on her knees. This incident occurred despite the resident's care plan clearly indicating the need for a total mechanical lift with two-person assistance. The incident was attributed to a miscommunication regarding the resident's transfer status. CNA staff believed the resident's transfer method had been changed by the therapy department, although the care plan had not been updated to reflect such a change. The Therapy Director confirmed that the resident had never been approved for the sit-to-stand lift due to her inability to bear weight. Despite the education provided to the CNAs following the fall, no audits were conducted to ensure compliance with care plans or to identify other residents who might have been affected.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with multiple medical conditions, including anal cancer, an open peri-anal surgical wound, colostomy, nephrostomy, and a suprapubic catheter. The resident was dependent on staff for personal hygiene and management of these medical devices. During an observation, a Certified Nursing Assistant (CNA) was seen providing care to the resident without wearing a protective gown, despite the resident's care plan and physician orders requiring EBP, including gown and glove use, for high-contact activities. The CNA was unaware of the EBP requirement, as there was no signage or personal protective equipment cart outside the resident's room to indicate the need for such precautions. The facility's policy on EBP, which aims to reduce the transmission of multidrug-resistant organisms, was not followed. This oversight resulted in the potential for the spread of infections, as the CNA did not adhere to the prescribed infection control measures during the resident's care.
Failure to Provide Meal and Assistance to Resident
Penalty
Summary
The facility failed to provide a meal and necessary assistance to a resident, identified as R13, who required help with eating. On the morning of September 25, 2024, R13 was heard calling out for breakfast, stating that staff refused to bring him his meal. The Speech Language Pathologist present at the time acknowledged the situation and intended to address it. R13, who had multiple diagnoses including diabetes and heart failure, was on a care plan that required extensive assistance with meals. Despite this, he did not receive breakfast because he was not in the dining room when meals were distributed, and staff did not bring him his tray. Further investigation revealed that the facility lacked a consistent system for ensuring all residents received their meals and for documenting reasons when meals were not consumed. Dietary staff reported that trays often returned untouched, sometimes without any notation of refusal. R13 was specifically noted to frequently have uneaten trays returned to the kitchen. The Dietary Manager occasionally informed nursing staff of uneaten trays, but there was no standard procedure to ensure all meals were offered and reasons for uneaten meals were recorded.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident with Parkinson's Disease, resulting in missed doses of a critical medication. The resident, who had been admitted with a primary diagnosis of Parkinson's Disease with dyskinesia, reported not receiving his Parkinson's medications upon admission and experienced delays in receiving them on subsequent days. Specifically, the resident did not receive the prescribed Amantadine HCl oral capsule 100 MG at the scheduled time on multiple occasions, including a significant delay on the morning of 9/25/24. The medical record review revealed that the first dose of Amantadine was not administered until 8:28 PM on the day of admission, despite being ordered for 7:00 AM. Additionally, there was no documentation of notification to the physician or pharmacist regarding the unavailability of the medication, which was an expectation according to the Registered Nurse Consultant. The facility's pharmacy policy indicated that medications needed before the next scheduled delivery should be ordered and requested STAT if not available in the emergency supply, which was not adhered to in this case.
Failure to Address Grievances and Inform Resident Representative
Penalty
Summary
The facility failed to inform a resident's representative of the grievance policy and procedure and did not promptly address all grievances submitted by the representative. This deficiency was identified during an abbreviated survey conducted in response to complaints about the facility's failure to provide staff assistance with personal hygiene and incontinence care for a resident. The resident, who had severe cognitive impairment and multiple medical conditions, was admitted with a care plan specifying the need for incontinence briefs in a specific location. Despite numerous emails from the resident's representative regarding care concerns, many were not documented in the facility's grievance log, leading to delays or omissions in grievance responses. The facility's grievance policy requires that all concerns be documented and addressed promptly, with the Administrator serving as the Grievance Officer responsible for overseeing the process. However, during the survey, it was revealed that the facility did not have grievance forms for all concerns identified in the emails from the resident's representative. The facility's policy mandates that written complaints be transcribed onto a concern form for follow-up, but this was not consistently done, resulting in a lack of evidence that all grievances were reviewed and resolved.
Failure to Maintain Resident's ADL Abilities
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain a resident's ability to perform activities of daily living (ADLs), resulting in inadequate grooming, dressing, personal hygiene, and toileting for the resident. The resident, who has severe cognitive impairment and a history of traumatic brain injury, was not provided with the necessary assistance and resources as outlined in their care plan. This included maintaining an adequate stock of incontinence briefs in a specified location, which was not adhered to, leading to the resident being found without briefs and in soiled clothing on multiple occasions. The resident's care plan, developed in collaboration with their representative, included specific interventions such as maintaining a preferred routine, ensuring the availability of briefs, and providing assistance with personal hygiene and toileting. Despite these interventions, the facility staff failed to consistently implement them, as evidenced by multiple complaints from the resident's representative. These complaints highlighted issues such as the resident wearing soiled clothes, not being shaved, and having a strong odor due to inadequate personal hygiene care. Interviews with facility staff confirmed the deficiencies in care. A CNA acknowledged that the resident was made to walk down a hallway with visible feces stains on their pants, which was inappropriate. The Nursing Home Administrator also acknowledged the ongoing concerns related to the provision of ADL treatment and services. The facility's failure to adhere to the care plan and provide necessary assistance resulted in the resident's inability to maintain personal hygiene and dignity.
Failure to Implement Comprehensive Wound Care Program
Penalty
Summary
The facility failed to implement a comprehensive wound care program, resulting in the development and worsening of multiple pressure injuries among residents. Resident R4 developed two facility-acquired unstageable/Stage 3 pressure injuries. Resident R19 developed a right heel wound infection requiring surgical debridement and IV antibiotics, and a new left heel deep tissue injury without proper interventions to prevent worsening. Resident R38's pressure injury deteriorated from Moisture Associated Skin Damage (MASD) to a Stage 4 pressure injury, requiring antibiotics for a subsequent wound infection. Resident R48 experienced worsening of a Stage IV sacral injury and was observed receiving inadequate wound care to prevent infection. Observations revealed that R19 was often found with his heels resting directly on the mattress or a flattened pillow, contrary to physician orders for heel protection boots and offloading heels. Despite orders for heel protection boots on both feet, R19 was frequently observed without the necessary protection on his left foot. Additionally, R19's wound care was inadequately performed, with improper wound dressing techniques and lack of adherence to Enhanced Barrier Precautions (EBP). R19's medical records showed inconsistencies in documenting care, including turning and repositioning, offloading heels, and pain management prior to appointments. The facility's documentation and care planning were found to be insufficient in addressing the residents' needs. R19's care plan lacked specific interventions recommended by the wound care physician, and there were no documented orders for offloading pressure from R19's heels prior to his hospitalization. The facility also failed to obtain and document wound clinic visit notes, which are crucial for ensuring continuity of care. These deficiencies highlight significant lapses in the facility's wound care management and documentation practices, leading to the deterioration of residents' conditions.
Inadequate Nursing Staff and Extended Call Light Wait Times
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in extended call light wait times and insufficient care. Multiple complaints were reported to the State Agency, indicating that residents were not receiving timely assistance with activities of daily living (ADLs) such as bathing, toileting, and oral care. Specific instances included a resident whose soiled linens were not changed promptly, causing embarrassment, and another resident who waited over 25 minutes for assistance after activating the call light. Additionally, a resident's representative reported excessive wait times for repositioning, toileting, and grooming, with call light logs showing multiple instances of wait times exceeding 15 minutes, and in some cases, over an hour. These issues were particularly prevalent between 5:00 PM and 7:00 AM, as confirmed by resident council members who noted a lack of staff after 2:00 PM daily. Interviews with residents and their representatives highlighted the emotional impact of these delays, with one resident feeling uncared for and like a nuisance to the staff. Attempts to interview CNAs and nursing staff about staffing issues were unsuccessful due to their fear of job loss. The facility's policy on call light response requires staff to answer call lights within 15 minutes, but this standard was not consistently met. The Nursing Home Administrator acknowledged instances where staff forgot to turn off call lights or left them on if they could not immediately resolve the requests, further contributing to the extended wait times.
Insufficient and Improperly Trained Dietary Staff
Penalty
Summary
The facility failed to ensure the dietary department was staffed with sufficient and properly trained personnel to carry out the functions and duties of the nutritional services department. During an interview, it was revealed that the Kitchen Manager (KM) had not completed the Certified Dietary Manager's (CDM) course and lacked credentials in food service sanitation, such as ServeSafe or Certified Food Service Manager (CFM). The KM had only completed about half of the CDM coursework. Additionally, the Registered Dietitian (RD) stated that his responsibilities were limited to clinical assessments and interventions, with no involvement in kitchen functions. The facility also had a corporate registered dietitian who consulted via phone but had not visited the facility to assist in training the KM for kitchen sanitation, menu, and recipe adherence, or other kitchen duties. The FDA Food Code 2017 requires that the person in charge demonstrate knowledge of foodborne disease prevention, application of Hazard Analysis and Critical Control Point (HACCP) principles, and the requirements of the code. This can be demonstrated by having no violations of priority items during the current inspection, being a certified food protection manager, or correctly responding to inspector's questions. The facility's failure to comply with these requirements has the potential to result in inadequate nutrition for all 73 residents.
Failure to Ensure Nutritional Adequacy and RD Approval of Menus
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of the residents, were followed and prepared according to the recipes, and were reviewed and approved by a Registered Dietitian (RD). On 5/20/24, it was observed that the facility's menus lacked evidence of RD review and approval. The Kitchen Manager (KM) confirmed that the menus were not formally approved by the corporate RD, and changes made to the menus were not approved by the RD. Additionally, the noon meal served on 5/20/24 did not meet the recipe requirements for protein content, as the Mostaccioli dish was prepared with only half the required amount of cottage cheese, resulting in insufficient protein for the residents. The cook responsible for preparing the dish admitted to not following the recipe accurately and not measuring the ingredients properly. Resident #22, who had a healing below-the-knee amputation and required adequate protein for healing, expressed concerns about the lack of protein in the meals. The resident showed the surveyor protein supplements she had ordered due to the facility's inadequate protein servings. The resident's medical records confirmed her need for a protein-rich diet due to her medical conditions, including amputation, anemia, and diabetes. The resident's lunch tray on 5/20/24 contained Mostaccioli with minimal visible cottage cheese, further supporting her claim of insufficient protein in the meals. Interviews with dietary staff revealed that the recipe for Mostaccioli was not followed correctly, and there was no proper documentation of the amount of food prepared and served. The Dietary Manager confirmed that the production cook did not always follow the recipes. The local Consulting RD also acknowledged the issue of inadequate protein in the facility meals, as raised by Resident #22. The facility's failure to ensure proper menu planning, recipe adherence, and RD approval resulted in potential nutritional deficiencies for all 73 residents.
Failure to Follow Menu Recipes and Maintain Nutritional Standards
Penalty
Summary
The facility failed to follow menu recipes to ensure the nutritional value of the food served to residents. During an observation of the noon meal, it was noted that the Mostaccioli being served did not contain the required amount of cottage cheese as per the recipe. The cook admitted to using only two and a half pounds of cottage cheese instead of the required five pounds for 50 servings. This discrepancy was confirmed through an interview with the kitchen manager, who also revealed that the facility did not maintain any records related to the amount of food used for meals, making it impossible to verify if recipes were being followed correctly. The facility's Menu Policy, which was reviewed, indicated that corporate menus are planned by a Corporate Registered Dietitian and can be altered with the approval of the facility or corporate RD. However, the facility failed to adhere to these guidelines, as evidenced by the lack of proper documentation and adherence to the recipe. This deficiency has the potential to result in nutritional deficiencies for all 73 residents of the facility.
Failure to Provide Physician-Prescribed Diets
Penalty
Summary
The facility failed to ensure that residents received diets as prescribed by a physician, specifically for one resident reviewed for therapeutic diets. Resident #25, who had a physician's order for a cardiac diet with regular texture and thin consistency, was observed receiving a meal that did not comply with the prescribed diet. The lunch tray included ham, cheesy potatoes, and caramel bread pudding, which are not appropriate for a cardiac diet. The facility's dietary software only supported a 2-gram sodium diet, which was not equivalent to the prescribed cardiac diet. The Dietary Manager was unaware of the differences between the diets and admitted that the facility did not have a diet manual to guide dietary choices. Additionally, there was no evidence that the menus had been reviewed by a Registered Dietitian (RD). Interviews with the Corporate Dietitian and the local Consulting Dietitian revealed that the facility's corporate software and lack of a diet manual contributed to the issue. The Corporate Dietitian admitted that the facility used a 2-gram sodium diet across the board to simplify procurement, despite the physician's specific order for a cardiac diet. The local Consulting Dietitian was unaware of this substitution and acknowledged the discrepancy. The facility's policy required that diet orders be entered electronically and menus be assigned accordingly, but the lack of a proper diet manual and RD review led to the deficient practice.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, Cook B was found to be preparing hot food, including a pan of Mostaccioli, which was measured to have temperatures significantly below the required 135°F. Despite Cook B's claim that the food was at 178°F, subsequent measurements showed temperatures between 120°F and 128°F. This discrepancy indicates improper temperature monitoring and potential risk for foodborne illness among the residents. Additionally, the facility's dishwashing practices were found to be inadequate. The mechanical high-temperature dish machine was not functioning correctly, with the sanitizing cycle failing to reach the required 160°F. Staff were observed pulling trays out of the machine before the cycle was complete, further compromising the sanitization process. Following a fire that rendered the dish machine inoperable, the facility resorted to using a three-compartment sink for dishwashing. However, the sanitizing solution was improperly tested, and the sink area lacked adequate space for soiled dish storage and drying, leading to unsanitary conditions. Further observations revealed that food service items were stored directly below unshielded cast iron sewer lines, posing a contamination risk. The Maintenance Manager was unaware of this storage issue. The facility's Kitchen Manager also admitted to a lack of training regarding the proper use and testing of sanitizing chemicals. These deficiencies highlight significant lapses in food safety and sanitation practices, potentially endangering the health of all 73 residents.
Deficiency in Pressure Ulcer Management and Leadership Support
Penalty
Summary
The facility failed to identify, assess, treat, and implement interventions to prevent and manage pressure ulcers effectively. The Nursing Home Administrator (NHA) could not provide evidence that the Quality Assurance and Performance Improvement (QAPI) committee had addressed skin and wound issues. The Director of Nursing (DON) presented a binder with incomplete documentation, lacking data analysis, action items, and tracking of pressure ulcers. The facility's policy on Quality Assessment and Process Improvement was outdated and not followed, as weekly meetings to discuss pressure ulcers were not held consistently, and there was no evidence of systematic identification, investigation, or analysis of pressure ulcer data. Additionally, the facility failed to provide adequate leadership resources to support nursing staff during increased staffing needs. The DON was reported to be under the influence of alcohol and unavailable for emergencies after hours. On one occasion, the DON was unable to come to the facility due to being four hours away, and the NHA was also unavailable until the next day. The facility did not have an on-call policy for supervision and nursing staff, and staff reported concerns about administration's lack of response to their requests for assistance and fear of retaliation. The facility's failure to administer its policies, practices, and procedures effectively and efficiently impacted the achievement and maintenance of the highest practicable physical, mental, and psychosocial well-being of each resident. The lack of proper documentation, data analysis, and leadership support contributed to the deficiency in managing pressure ulcers and addressing staffing needs during emergencies.
Failure to Conduct and Document Annual Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document an annual facility-wide assessment, resulting in the potential for inadequate knowledge of the facility population's needs and resources to care for the 73 residents. The Nursing Home Administrator (NHA) provided a Facility Assessment that was outdated and reflected the previous ownership. The NHA stated that the assessment had been reviewed and signed on 10/16/23, but it did not reflect the current resident population. The Minimum Data Set (MDS) Resident Population Profile was dated 10/28/21-10/27/22, and the Patient Population was dated 10/2022, which did not reflect the current resident population. The NHA and Regional Clinical Resource nurse mentioned they were waiting for updated guidelines from the Centers for Medicare and Medicaid Services (CMS) before updating the Facility Assessment.
Failure to Maintain Effective QAPI Program for Pressure Ulcers
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance & Performance Improvement (QAPI) program to address and correct identified quality deficiencies. During an interview, the Nursing Home Administrator (NHA) stated that the QAPI committee met monthly to discuss departmental projects and systems improvements. However, there was no evidence that the committee had addressed skin and wound issues, specifically the prevention and treatment of pressure ulcers. The NHA could not provide documentation demonstrating performance improvement activities in this area, and the QAPI committee minutes lacked analysis of data tracking and trending or system improvements related to pressure ulcers. The survey team identified an immediate jeopardy situation due to the facility's failure to identify, assess, treat, and implement interventions to prevent and heal pressure ulcers. The Director of Nursing (DON) presented a binder on pressure injuries, which included an undated education sign-in sheet and a policy but lacked data analysis or action items. The DON could not provide data on the tracking or trending of pressure ulcers for several months, nor could they confirm how many pressure ulcers were currently present. There was no evidence that this topic had been reported to the QAPI committee or was part of the QAPI program. The facility's policy on Quality Assessment and Process Improvement indicated that pressure injuries should be discussed weekly, but the DON confirmed that weekly meetings had ceased. The policy also stated that all identified problems, especially high-risk areas like pressure ulcers, should be addressed through systematic identification, investigation, and analysis. However, the facility failed to adhere to these guidelines, resulting in a system failure in the skin and wound program, which had the potential to affect all 73 residents in the facility.
QAPI Committee Composition and Attendance Deficiency
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required members and met the necessary attendance criteria. During an interview, the Nursing Home Administrator (NHA) stated that the QAPI committee met monthly and included each department head. However, a review of the Quality Assurance and Performance Improvement Committee Meeting Attendance Record sign-in sheets revealed several deficiencies. On multiple occasions, the Medical Director was absent, and other department heads were not present to report on issues in their areas. Additionally, there were no sign-in sheets for several quarters, and the meetings did not include direct care staff as required by the facility's policy. The facility's policy on Quality Assessment and Process Improvement, dated 10/15/2018, mandates that quarterly QAPI meetings be documented with sign-in sheets and minutes, and that direct care staff be present to provide feedback and insight. The policy also specifies that the QAPI committee should be interdisciplinary and include the Director of Nursing, a physician, at least three other staff members, and the Infection Prevention and Control Officer. The facility's failure to adhere to these requirements resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 73 residents at risk for quality care concerns.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, leading to multiple deficiencies. On 5/19/24, water was observed on the floor under the three-compartment sink and refrigerator, attributed to an overflowing drain that could not handle the flow from the sinks. Cook C and Kitchen Manager A confirmed this issue had been ongoing. Maintenance Manager E also acknowledged the long-standing problem with the kitchen drain. Additionally, on 5/19/24, a smoke odor was detected near the nurses' desk, traced back to an overheated mechanical dish machine in the kitchen. The machine had been malfunctioning since its installation in February, requiring frequent servicing. A sensor from the soap dispenser was found burnt and disconnected, contributing to the overheating event. Despite assurances from the vendor, the machine remained unrepaired by 5/21/24, leaving the facility without a working dish machine. These deficiencies highlight the facility's failure to ensure proper maintenance of essential kitchen equipment, posing potential risks to staff and residents. The ongoing issues with the kitchen drain and the malfunctioning dish machine were confirmed through multiple interviews with kitchen and maintenance staff. The lack of timely and effective repairs exacerbated the situation, leading to unsafe conditions in the kitchen area.
Failure to Follow Grievance Process
Penalty
Summary
The facility failed to follow through with the grievance process initiated by resident representatives and the resident council. Resident representatives voiced concerns that their grievances were not addressed, and they had not been notified of any action taken. A specific grievance filed by a resident's representatives on 2/7/24 was marked as resolved, but follow-up interviews revealed that no follow-up had been conducted. Additionally, the resident council had repeatedly raised concerns about the lack of evening snacks in their meetings from January to April 2024, but these grievances were not addressed either. The activities director confirmed that the grievances were filed, but the residents still did not receive their evening snacks regularly. Confidential staff also reported that some grievance forms were found in the trash in the Nursing Home Administrator's office without any follow-up being completed, raising concerns about the adherence to the grievance process. The facility's policy on Investigations of Grievances, dated 10/1/22, states that concerns should be forwarded to the relevant department for resolution and that the Director of Nursing is responsible for ensuring proper investigation and follow-up. The Administrator, as the designated grievance official, is responsible for reviewing each written grievance for proper investigation, follow-up, and resolution. However, the facility failed to adhere to this policy, resulting in unresolved grievances and a lack of communication with the complainants. This deficiency affected the residents' ability to have their concerns addressed and resolved, particularly regarding the provision of evening snacks.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to four out of seven staff members reviewed. The computerized software education for QAPI was not found for Staff N, P, R, and Q. Interviews with various staff members, including housekeeping staff, CNAs, and an RN, revealed a lack of awareness and understanding of the facility's quality improvement projects and goals. Staff members reported receiving papers to read and sign without any formal classes or retaining copies, and they were generally unaware of the specific quality projects and goals the facility was working on. The facility's policy on Quality Assessment and Process Improvement, dated 10/15/2018, was found to be outdated and lacked recent review dates and necessary approvals. The policy suggested various communication methods to keep staff informed, such as communication boards, staff meetings, newsletters, and drop boxes for improvement ideas. However, these methods were not effectively implemented, as evidenced by the staff's lack of knowledge about the facility's quality improvement initiatives. The NHA acknowledged the deficiency, confirming that the computerized software education logs indicated incomplete training for the identified staff members.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure the appropriate care of indwelling urinary catheter equipment for one resident, resulting in the potential for contamination and urinary tract infection. The resident, who was admitted with diagnoses including diabetes and urethritis, was observed with catheter tubing resting directly on the floor. Additionally, during preparation for an outside appointment, a CNA placed a plastic cylinder on the floor beneath the drainage bag and emptied the urine without disinfecting the spout, citing a lack of access to alcohol swabs. The drainage bag subsequently fell to the floor and was picked up by another CNA, who placed it back in the cover and hooked it to the bed frame without disinfecting it. Both CNAs acknowledged that catheter drainage bags and tubing should not touch the floor to reduce infection risk. The Nurse Manager confirmed that the facility's standards of practice require catheter drainage bags and tubing to be positioned so that no portion touches the floor and that the drainage spout should be disinfected after emptying urine. The facility's policy on catheter care and the CDC guidelines for preventing catheter-associated urinary tract infections both emphasize the importance of keeping catheter equipment off the floor and disinfecting the drainage spout to prevent bacterial contamination. The observations and interviews revealed a failure to adhere to these standards, posing a risk of infection to the resident.
Failure to Assess Respiratory Status for Resident Receiving As-Needed Respiratory Medications
Penalty
Summary
The facility failed to assess the respiratory status of a resident (R168) who was receiving as-needed respiratory medications and supplemental oxygen, according to professional standards of practice. R168, who had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed using a nasal cannula connected to a portable oxygen concentrator and had a nebulizer on the nightstand. Despite the resident's continuous use of supplemental oxygen and as-needed use of the nebulizer, there were no documented respiratory assessments or oxygen saturation levels recorded after the initial assessment on the date of admission. The review of R168's Medication Administration Record (MAR) and Electronic Medical Record (EMR) revealed multiple instances of administered respiratory medications without corresponding respiratory assessments. Interviews with Registered Nurses (RN) K and J confirmed that respiratory assessments are a standard practice when administering as-needed respiratory medications, but no such assessments were documented. Additionally, R168's care plan lacked focus areas, measurable goals, or interventions related to COPD and the use of continuous oxygen or as-needed respiratory medications. The facility's policies on baseline care plans and oxygen administration did not include procedures for respiratory assessments after the administration of supplemental oxygen.
Failure to Properly Administer and Document Insulin Dose
Penalty
Summary
The facility failed to ensure the proper administration and documentation of an insulin dose for a resident. During an observation, a Registered Nurse (RN) was seen preparing to administer 36 units of Lantus Solostar insulin to a resident. The RN did not have a secure grip on the insulin pen, resulting in only 26 units being administered initially. The RN then attempted to administer the remaining 10 units but only managed to deliver 5 units. Despite these errors, the RN documented in the Medication Administration Record (MAR) that the full 36 units were administered. The Director of Nursing (DON) was unaware of the incident and confirmed that the attending physician should have been notified and the correct dosage documented. A review of the resident's Electronic Medical Record (EMR) revealed no documentation or physician notification regarding the incorrect insulin dose. The DON stated that the facility's procedure is to alert the attending physician when medication errors occur and to assess the resident for any ill effects. The failure to document the correct dosage and notify the physician could lead to potential issues with the resident's glucose levels and future insulin dosage adjustments.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less, resulting in a medication error rate of 8.57%. During an observation, a Registered Nurse (RN) prepared and administered medications to a resident, including Keppra, Toujeo Max Solostar, and Humalog. The RN administered only 500 mg of Keppra instead of the prescribed 1000 mg. Additionally, the RN did not hold the insulin needles in place for the required five seconds, withdrawing them after only three seconds. This was confirmed by the RN's own admission and the facility's policy, which aligns with the manufacturer's guidelines for insulin administration. Further interviews revealed that the Nurse Manager was unaware of the correct duration for holding insulin needles in place and had to contact the pharmacy for the manufacturer's instructions. The facility's policies on medication and insulin administration were reviewed and found to require adherence to the manufacturer's guidelines, which were not followed in this instance. This led to the observed medication errors and the resulting citation.
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.
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