Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Troy during CMS and state inspections, most recent first.
Infection control surveillance and the WMP were not effectively maintained. A resident with MRSA sputum was placed on EBP even though the DON later confirmed CDC guidance called for contact precautions, and the facility’s influenza outbreak records were incomplete because documentation covered only the first floor despite second-floor residents also having influenza. The WMP binder was outdated, listed former staff, contained old pages and blank logs, had no recent WMT meetings or monitoring records, and the MD reported no WMP-specific training and no recent team activity.
Improper bedside storage of resident medications: Four residents had medications or treatments left at the bedside or in open drawers, including antacid tablets, Flonase, antifungal powder, Desenex, and diclofenac gel. Residents stated some items were not ready to take or were being used by them, but self-administration assessments were not completed for any of the residents. An LPN stated one bottle should not have been left in the room, and the DON said medications and treatments should be stored in medication carts.
Antibiotic stewardship was not effectively implemented when McGeer criteria were incorrectly applied for multiple residents receiving antibiotics. Records showed urine cultures and other diagnostic results that did not match the criteria marked on the worksheets, yet antibiotics were still given for UTI or pneumonia. The IP LPN stated she had not been working at the facility frequently, misunderstood culture thresholds, believed a sensitivity result meant antibiotics were needed, and said she was not able to stop antibiotics.
Ice machine drain lines in multiple nourishment rooms were observed terminating below the flood rim, and two were soiled with a black substance. Staff E stated he was not aware of the concern and said it would be corrected.
Inadequate Shower Water Temperatures: A resident reported that shower water in the central shower area was cold or barely warm and uncomfortable, while surveyors measured shower temperatures below the facility policy minimum in multiple showers. Sink water in other areas reached acceptable hot temperatures, but shower water in the central shower rooms fluctuated and did not stay hot enough for bathing. Staff said only one or two residents regularly complained and that concerns were entered into the electronic maintenance system.
A facility failed to provide consistent, individualized activity programming for several residents. Surveyors observed long periods with no activities, limited weekend and morning programming, and repeated reliance on a few group events such as BINGO and coffee chat. Residents reported boredom, missed activities, lack of variety, no outings, and little to no in-room engagement, while staff confirmed staffing shortages and that the ADON/Activity Director was often running activities alone.
Improper Storage of Smoking Materials: A resident with dx including cirrhosis, dysphasia, and alcohol abuse, and with moderate cognitive impairment, was observed smoking near the entrance of a smoke-free facility. The resident’s record showed a smoking evaluation and care plan related to smoking history, but cigarettes provided by a family member were not being stored by the facility and two packs were later found in the resident’s drawer.
Controlled Medication Documentation Not Followed: An LPN and an RN did not follow the facility’s controlled medication protocol during morning med pass for two residents. Each nurse removed a controlled med from the locked cabinet, took a pill from the packet, returned the packet to the locked box, and later administered and signed off the meds, but did not document the quantity removed and quantity left on the controlled drug record when the medication was taken from the packet as required by policy.
A resident with Parkinson’s disease, dementia, severe cognitive impairment, and a guardian had a documented history of nighttime wandering into other residents’ rooms, entering roommates’ space, flooding a bathroom, urinating on the floor, grabbing a nurse’s breast multiple times, hitting a nurse on the rear, making sexual remarks to female staff, and attempting to get into bed with another resident who tried to push him away. Despite these repeated behaviors, effective care plan interventions for wandering and sexually focused behaviors were not implemented for an extended period, and the resident was moved to a unit housing many highly vulnerable residents with dementia. Later, a CNA found this resident in bed with a non-verbal, severely cognitively impaired female resident, with his hand down the front of her brief, after camera footage showed he had entered her room and remained there for over an hour without staff stationed outside his room as care-planned; staff also did not use translation tools they normally used to communicate with him, and the female resident’s guardian was not fully informed that his hand had been inside her brief.
A resident with a history of TIA and cerebral infarction reported new stroke-like symptoms, including left-sided weakness and inability to grasp with the left hand. Despite these symptoms and family concerns, staff did not provide ongoing assessment, follow recommended monitoring, or send the resident for further evaluation. The resident missed two neurology appointments before being sent to the hospital, where imaging revealed a new chronic infarct. The facility lacked a stroke protocol and did not ensure timely intervention or follow-up.
Failure to report resident-to-resident abuse and sexual misconduct: A male resident with intermittent confusion and sexually inappropriate behaviors entered two female residents’ room, attempted to get into bed with them, and exposed/fondled himself. One resident reported feeling scared and said staff response was delayed, while another resident struck him with a shoe as he was being removed. The facility did not promptly report the incident to the State Agency and police as required by policy.
A resident with a history of gangrene and recent toe amputation experienced a worsening wound and required hospitalization after the facility failed to ensure timely wound care and specialist follow-up. The resident missed a critical appointment due to being sent to the wrong location, experienced delays in treatment, and did not receive recommended antibiotics. Staff did not consistently use translation services to address the resident's language barrier, and documentation showed lapses in communication and follow-up.
A resident with dementia, impaired cognition, and blindness, who required 24-hour supervision, was sent alone to multiple medical appointments without staff accompaniment. Despite documentation of the resident's inability to make medical decisions or provide history, facility staff failed to ensure appropriate supervision during transportation, and interviews revealed unclear procedures for determining when staff should accompany residents.
Two residents experienced significant changes in condition that were not properly identified or addressed by staff, including delayed physician notification, ineffective antibiotic treatment, and lack of timely follow-up on abnormal symptoms and test results. One resident died from septic shock secondary to UTI and pneumonia after staff failed to act on clear signs of decline, while another was transferred to the hospital for respiratory distress after delayed assessment and intervention for cardiac and respiratory symptoms.
A resident with complex medical needs experienced multiple hospitalizations after staff failed to timely identify, assess, and report changes in condition, did not consistently monitor or document vital signs before medication administration, and administered oxygen without a physician order. Incomplete nursing notes, failure to implement physician orders for IV therapy, and lack of timely transfer to a higher level of care were also observed, contributing to adverse outcomes.
A resident with severe malnutrition and dysphagia experienced significant unaddressed weight loss due to delayed nutritional assessments, lack of timely interventions, and poor interdisciplinary communication. Despite ongoing poor intake, requests for GI referral and PEG tube placement were not promptly followed up, and dietary supplements were not administered as ordered. The resident was hospitalized twice for acute changes in condition and ultimately died with severe calorie malnutrition.
A resident with a history of orthopedic injuries, requiring two-person assistance for bed mobility and incontinence care, sustained a distal tibia fracture when an agency CNA provided care alone and the resident's leg slipped off the bed and hit the floor. The CNA was not informed of the two-person assist requirement, and the facility's investigation lacked comprehensive staff interviews or evidence of staff education regarding adherence to care plans.
A resident with dementia and a history of cancer had a valid DNR order signed by both the resident and physician, but the EMR incorrectly listed the resident as "Full code." Both nursing and social work staff initially referenced the incorrect code status, only discovering the error after further review. Facility policy requires accurate documentation and display of code status, but this was not followed, resulting in staff confusion about the resident's end-of-life care wishes.
A resident with Parkinsonism and intact cognition reported being physically abused by a nurse during incontinence care after accidentally kicking the nurse out of fear of falling. The nurse allegedly struck the resident and refused to complete care, but denied the incident when interviewed. The facility substantiated the abuse based on the resident's consistent account and cognitive status, documenting violations of abuse, rudeness, and negligence by the nurse.
A resident with a history of orthopedic issues sustained a tibia and fibula fracture during care by an agency CNA. The resident reported pain and fear after the incident, but staff did not notify the Administrator or State Agency until several days later, after x-ray confirmation. Facility policy requiring immediate reporting of such incidents was not followed, resulting in a deficiency for delayed reporting of alleged abuse and injury of unknown origin.
The facility did not thoroughly investigate an injury of unknown origin and an allegation of mistreatment for a resident, and failed to prevent further access between a resident and an employee with confirmed abuse findings, as required by policy.
A dependent resident with dementia and incontinence was left yelling for assistance while staff at the nursing desk did not respond. The resident was found poorly positioned in bed, with a wet brief and the call light out of reach. Staff interviews revealed incontinence care had not been provided during the shift, and care plans for positioning and call light access were not followed, resulting in a deficiency related to timely ADL care.
Staff did not follow facility policy for assessing and documenting a resident's decision-making capacity. After concerns about cognition were raised, only one physician evaluated the resident, and the required documentation was incomplete and not properly filed. The attending physician signed the capacity form without a current face-to-face exam, and the original form was missing from the medical record.
A resident with a history of orthopedic issues sustained a leg fracture while being cared for by an agency CNA, who did not follow the care plan requiring two-person assistance. The facility's investigation was incomplete, with only one staff statement obtained and no documentation of interviews with other staff or residents, nor evidence of staff education or disciplinary action.
A resident with Parkinsonism and intact cognition reported being physically abused by a nurse during incontinence care. Despite the facility substantiating the abuse allegation and the resident's request not to be assigned to the nurse, the nurse continued to provide care and administer medications to the resident after the incident, contrary to facility policy requiring immediate removal of staff involved in abuse allegations.
The facility failed to maintain operational mechanical lifts, affecting three residents' ability to be safely transferred and participate in activities. Residents reported issues with lift batteries not holding a charge, leading to mobility restrictions and safety concerns. Staff struggled to find charged batteries and operational lifts, impacting resident care. The Maintenance Director noted that routine maintenance was delayed due to unpaid bills, and the facility lacked a proper system for logging repair needs.
The facility did not ensure grievances from residents in the resident council meetings were documented, investigated, tracked, and resolved. During a group meeting, several residents reported that their concerns were not addressed or resolved in a timely manner. A review of meeting minutes revealed concerns with nursing services, but the facility had no documentation showing these concerns were addressed. The Activities aide confirmed the absence of a grievance resolution form for the nursing services concerns.
The facility failed to meet professional standards for four residents, including incorrect documentation of a resident's status, improper medication administration, mishandling of a stool sample, and an untestable urine specimen due to labeling errors. These deficiencies highlight lapses in documentation, medication protocols, and infection control processes.
A resident with a history of intraspinal abscess, meningitis, and rheumatoid arthritis experienced discrepancies in the documentation of Hydromorphone administration. The facility's records showed tablets being removed without corresponding entries on the MAR, and times were altered on the MAR. The DON was informed of these issues, which involved eight unaccounted tablets.
The facility failed to store medications safely and appropriately, as observed in multiple medication carts. Coffee was found in a cart drawer, and several medications, including insulin and inhalers, were undated despite being opened and used. Additionally, an unlocked and unattended treatment cart was observed, which the DON confirmed was against policy. These findings indicate lapses in adherence to medication storage policies.
The facility failed to ensure proper infection control practices for two residents on transmission-based precautions, leading to potential infection spread. A CNA did not follow PPE protocols for a resident with Candida auris, and there was confusion over signage and precautions for another resident on IV antibiotics. Staff, including a new Infection Preventionist, were not fully informed about necessary precautions, resulting in inconsistent practices.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving two residents. One resident was instructed to urinate in their brief instead of being assisted to the bathroom, while another was observed without proper clothing, only wearing a brief or gown. Additionally, three anonymous residents reported feeling disrespected by staff. These incidents highlight systemic issues in the facility's approach to resident dignity.
A resident's privacy was compromised during a blood draw as the procedure was visible from the hallway due to an open door and curtain. The Unit Manager confirmed the lack of privacy, and the phlebotomist did not respond when questioned about the oversight. The resident had a diagnosis of MSSA, and the facility could not provide a privacy policy when requested.
A facility failed to document and communicate a resident's transfer to the hospital, resulting in a deficiency. The resident, with diagnoses including diabetes and dementia, was sent to the hospital, but necessary transfer documentation was not completed. The resident remained listed as active in records, and progress notes inaccurately showed the resident as present in the facility. Staff interviews revealed a lack of communication and oversight in the discharge process.
A resident admitted for rehabilitation after a fall continued to receive Trelegy Ellipta despite pharmacy recommendations against it. The DON confirmed the medication was administered without clarifying the order with the physician, contrary to facility policy requiring review of new admission orders with the physician.
The facility failed to provide adequate pressure ulcer care for two residents. One resident's heel breakdown was not communicated to the wound care nurse in a timely manner, while another resident with a stage III sacral ulcer did not receive consistent treatment as per the prescribed plan. Discrepancies in treatment orders and missed applications contributed to the deficiency.
The facility failed to conduct timely skills and competency evaluations for two CNAs, with the last evaluations completed over a year ago. The In-Service Director confirmed the lapse, noting that evaluations should be annual. Documentation provided included only a blank skills checklist.
The facility failed to complete physician-ordered lab tests for two residents, resulting in a deficiency. One resident with severe cognitive impairment and hemiplegia did not have a CBC with differential completed due to an incorrect entry in the EMR. Another resident with end-stage renal disease and cerebral infarction did not receive weekly CBC and CMP tests as ordered, with only one set of results available.
A facility failed to communicate significant changes in a resident's condition to hospice services. The resident, under hospice care for multiple medical conditions, experienced discomfort and was diagnosed with a urinary tract infection. Despite facility policy requiring notification of such changes, the hospice nurse was not informed, leading to a lack of collaboration on the resident's care plan.
The facility did not ensure nurse staffing information was accessible for residents and visitors, with missing postings on several dates over three months. The Administrator indicated the scheduler and receptionist were responsible for posting, but multiple instances of missing documentation were found.
A resident reported issues with receiving timely assistance for bathroom needs, which were not adequately addressed by the facility. Despite the resident's complaints, the facility failed to ensure timely help, as evidenced by a CNA forgetting to assist the resident after turning off their call light. The facility's grievance process was incomplete, with no formal education or documentation on call light response, leading to a deficiency in resolving the resident's grievance.
A facility failed to report an allegation of abuse involving a resident to the State Agency. The resident, with diagnoses including Morbid Obesity and a Pressure ulcer, was reportedly pushed by a CNA. The incident was reported by the resident's family, who also notified the police. Despite the police finding no evidence, the facility did not report the allegation to the State Agency, violating their policy requiring immediate reporting of such incidents.
A facility failed to follow a resident's bed mobility plan of care, which required two-person assistance. A CNA performed the task alone, contrary to the care plan, leading to a deficiency in providing adequate supervision to prevent accidents. The resident, with moderately impaired cognition, was dependent on staff for most activities of daily living.
A facility failed to ensure a CNA received required training on abuse policies before working with residents, leading to an incident where a resident was allegedly pushed by the CNA. The resident, who had impaired cognition and required assistance with daily activities, reported the incident to family, prompting a police investigation. The facility lacked documentation of the CNA's training, despite policies requiring such training upon hire and annually.
A resident reported issues with timely medication administration and lack of follow-up on grievances. Despite emailing the DON, the concern was not documented on a grievance form. The resident's medical record showed they required assistance with daily activities and had intact cognition. The facility's grievance log lacked documentation of the medication concern and other grievances were incomplete, violating the facility's grievance process policy.
A facility failed to develop a comprehensive care plan for a resident with complex urinary conditions, including recurrent UTIs with multidrug-resistant bacteria, a ureteric stent, and chronic kidney disease. Despite hospital documentation detailing the resident's medical history and treatment needs, no care plan was created to address these issues. The Director of Nursing acknowledged the oversight but did not provide further documentation.
A resident with multiple diagnoses, including dementia and sciatica, did not receive timely showers as per their care plan. Despite being cognitively intact and requiring assistance with transfers, the resident only received bed baths over three weeks after admission. Complaints were filed alleging inadequate grooming, and documentation showed no record of shower refusals or requests for bed baths, contrary to facility policy.
A resident with serious medical conditions experienced difficulty breathing, but the facility failed to perform a complete assessment or notify the physician. Despite the family's request for hospital transfer, the facility did not act, leading the family to call 911. The resident was later admitted to the ICU with sepsis, highlighting lapses in care and communication.
A resident with acute respiratory failure and hypoxia did not receive continuous oxygen as prescribed. A family member found the oxygen concentrator off and informed the nurse, who was unaware of the issue. The DON confirmed that continuous oxygen should be provided without exception, but no further documentation was provided by the facility.
A facility failed to implement a baseline care plan for a resident with chronic respiratory failure and a tracheostomy, who required continuous enteral feeding. The care plan lacked an intervention for proper positioning, which is essential for preventing complications. This deficiency was discovered after the resident was found unresponsive, highlighting the facility's failure to follow its standard practice of implementing necessary interventions upon admission.
Infection Control Surveillance and Water Management Program Failures
Penalty
Summary
The facility failed to implement an effective infection control surveillance program and transmission-based precautions for a resident with MRSA sputum. A physician order dated 3/6/26 directed Enhanced Barrier Precautions for the resident, who had diagnoses including Influenza A virus, respiratory failure, heart failure, and chronic kidney disease. However, a sign on the resident’s room door indicated EBP, while the DON stated the resident had initially been on contact precautions and had recently been changed to EBP. After reviewing CDC guidance, the DON stated the resident was supposed to be on contact precautions and would be fixed immediately. The infection control surveillance records were incomplete. The facility reported an Influenza outbreak in February 2026, but the surveillance books provided did not document the outbreak in a single complete record. The outbreak surveillance included line listings and mapping for the first floor only, and there was no documentation for residents on the second floor. Review of resident records showed some second-floor residents had Influenza in February 2026, and the DON confirmed there were second-floor residents with Influenza, but no surveillance documentation for them was provided before the end of the survey. The facility also failed to maintain an active Water Management Program. The WMP binder at the front desk contained a plan dated 2/19/24, but there was no evidence it had been reviewed or updated since then. Team member names listed in the plan were no longer current, several pages remained dated 2/14/2019 without revisions, and the water system description was text only and not current. Monitoring logs in the binder were blank or dated 2020-2021, the last quarterly Water Management Team meeting sign-in sheet was dated 2/22/22, and there were no recent records for disinfectant residuals, water temperatures, flushing protocols, or team meetings. The Maintenance Director stated he had not completed WMP-specific training, there had not been any WMT meetings in the past year, and the facility provided no additional updated WMP documentation beyond an emergency preparedness water outage policy.
Improper bedside storage of resident medications
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications left at the bedside for four residents reviewed for medication storage. On 3/9/26, R147 was observed in bed with two large round tablets in a medication cup on the bedside table and stated the medications were an antacid they were not ready to take yet; the record showed no self-administration assessment had been completed. R102 was observed with inhalers (Flonase) and antifungal powders in an open nightstand drawer and stated the medications came from the hospital; no self-administration assessment was completed for R102. R146 was observed with a yellow bottle of Desenex at bedside, and the assigned LPN stated the bottle should not have been left in the resident's room and should be locked in the treatment cart; the record showed no self-administration assessment was completed for R146. R93 was observed in bed with two tubes of diclofenac sodium 1% gel and stated they tried to apply the gel themselves but had difficulty reaching body parts; no self-administration assessment was completed for R93. The DON stated medications and treatments should be stored in medication carts and that nurses are responsible for each medication. The facility policy stated all medications and biologicals are to be stored in locked compartments.
Antibiotic Stewardship Program Not Effectively Implemented
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program to ensure infection criteria were met for five residents who received antibiotics. During review of the December 2025, January 2026, and February 2026 antibiotic surveillance records, no line listings were documented for December 2025, and McGeer Criteria Worksheets were completed for residents with urine culture results that did not match the criteria marked on the forms. For one resident, the worksheet indicated leukocytosis and microbiology criteria for a UTI, but the urine culture showed no growth and the resident received ciprofloxacin for 3 days. Another resident’s worksheet marked UTI criteria, but the chest x-ray showed patchy airspace opacities and subsegmental consolidation concerning for pneumonic infiltrate, and the resident received doxycycline for pneumonia for 7 days. Additional records showed a resident’s worksheet marked a UTI criterion of at least 100,000 CFU/ml when the urine culture grew 15,000 CFU/ml each of E. coli and Klebsiella pneumoniae, and the resident received ciprofloxacin for 7 days. Another resident’s worksheet marked a UTI criterion when the urine culture showed alpha-hemolytic strep species at 30,000 CFU/ml, and the resident received linezolid for 7 days. A fifth resident’s worksheet marked a UTI criterion when the urine culture grew Klebsiella pneumoniae at 60,000 CFU/ml, and the resident received levofloxacin for 7 days. The infection preventionist stated she had not been working at the facility frequently lately, believed 10,000 was 10 to the fifth power, thought a sensitivity result meant the resident needed an antibiotic, and stated she was not able to stop antibiotics. The facility policy stated that McGeer criteria are used to determine infection and that diagnostic test results not meeting criteria will be reported to the medical practitioner for further evaluation of need.
Ice Machine Drain Lines Improperly Positioned and Soiled
Penalty
Summary
The facility failed to ensure appropriate cross-connection prevention, resulting in the potential for contamination of ice in the ice machine and affecting all residents. During observation, the unit 300 nourishment room ice machine drain line was seen terminating below the flood rim and was soiled with a black substance. The unit 100 nourishment room ice machine drain line was also observed terminating below the flood rim. In addition, the 2nd floor nourishment room ice machine drain line was observed terminating below the flood rim and soiled with a black substance. When Staff E viewed each of these conditions, he stated he was not aware of the concern and that it would be corrected.
Inadequate Shower Water Temperatures
Penalty
Summary
The facility failed to provide a safe, home-like environment by not ensuring comfortable water temperatures for residents using the central shower rooms, including one resident who reported that shower water was cold or barely warm. A complaint alleged the facility had not had enough hot water for at least three months, and the complainant understood the needed water heater part had not been purchased because the facility had to go through its corporate company. When asked about hot water, the resident stated the shower water was too cold and uncomfortable, and that they liked hot water for showers. Surveyors measured water temperatures in multiple areas and found sink temperatures in vacant rooms and the central shower room at 102F and 104F, while the central shower room shower measured 94F. On the second floor, the dining room sink measured 112F, but the resident stated the dining room sink got hot enough while the shower area did not and fluctuated without staying hot enough for a shower. Additional measurements in the second-floor central shower room showed shower temperatures of 103F and 101F at 3 minutes, dropping to 96F and 97F at 5 minutes. Staff stated that only one or two residents regularly complained about showers not being hot enough and that concerns were entered into the electronic maintenance system. The facility's Safe Water Temperatures policy stated resident area water temperatures should be no more than 121F and not less than 105F or the state's allowable maximum water temperature.
Inconsistent and Limited Activity Programming
Penalty
Summary
The facility failed to provide consistent activity programming with meaningful individualized activities to meet the interests and needs of five residents reviewed for activities. Survey observations on multiple days found no activities occurring in the morning or in common areas at times when residents were present, and several residents were observed sitting in the dining room, near the nurses’ station, or in their rooms without engagement. The activity calendar showed scheduled programs seven days a week, but the actual delivery of activities was limited, repetitive, and often centered on a small number of group events such as BINGO, coffee and chat, chair exercise, and tea parties. Resident interviews described boredom, missed activities, and a lack of variety. One resident said there were not enough activity staff, that activities were missed most mornings and on weekends, and that a prior activity staff member who provided more varied crafts had not been replaced. Another resident said the programming was repetitive, that the activities were mainly held in the same upstairs location, and that there were no true physical activities or outings. A younger resident said there was nothing to do, that no one came to invite them to activities, and that they wanted more games, reading materials, and outings. A resident who was often in bed said activity staff used to bring more activities to the room, but now mainly brought a newsletter and treat, with no books, magazines, or crafts offered. Staff interviews confirmed limited staffing and inconsistent participation by activity aides. The Activity Director stated there had not been enough assistance transporting residents and completing activities consistently since a former aide left, and acknowledged there were not enough activities on weekends and no activities on some Saturdays because there was no staff available. Surveyors observed the Activity Director transporting residents and running activities alone while the activity aides were not participating. The facility’s policy required an ongoing program of activities designed to meet each resident’s interests, choices, and preferences and to include individual, small group, large group, in-room, sensory, exercise, religious, outdoor, and outing activities, but the observed program did not consistently reflect those requirements for the residents reviewed.
Improper Storage of Smoking Materials
Penalty
Summary
The facility failed to ensure proper storage of smoking paraphernalia for one resident who was reviewed for smoking and accidents. The facility policy identified the building as smoke-free, prohibited residents from smoking on facility property, and stated the facility could confiscate smoking items and paraphernalia to ensure resident and staff safety. During the entrance conference, the Administrator reported the facility was non-smoking and did not identify any residents who smoked. On 3/11/26, the resident was observed leaning on a pole near the front entrance smoking a cigarette, and a CNA reported being outside with the resident. The resident stated they liked to smoke outside and did not respond when asked about the facility being non-smoking. The resident's record showed diagnoses including cirrhosis of the liver, dysphasia, and alcohol abuse, an MDS BIMS score of 11/15 indicating moderate cognitive impairment, and a physician statement that the resident lacked capacity to make reasonable medical decisions and/or provide informed consent to their medical affairs. The record also included a smoking evaluation stating the resident would relinquish smoking materials to the nurse to be locked up between LOAs, and a care plan noting a history of smoking. The Administrator later stated cigarettes were being provided by a family member and the facility was not storing them, and the resident was observed with two packs of cigarettes in a drawer in their room.
Controlled Medication Documentation Not Followed
Penalty
Summary
The facility failed to ensure that two nurses followed the protocol for controlled medication administration for two residents. During observation, an LPN prepared morning medications for one resident and included morphine sulfate 15 mg extended-release tablet. The LPN unlocked the controlled medication cabinet, removed the morphine, took one pill from the packet, returned the packet to the locked box, continued preparing the resident’s other medications, and later administered the medications and signed them off as given. When asked when the controlled medication would usually be signed out on the controlled medication log, the LPN stated they usually sign out the medication as they go but were nervous. During a separate observation, an RN prepared morning medications for another resident and included Klonopin 0.5 mg tablet. The RN unlocked the controlled medication cabinet, removed the Klonopin, took one pill from the packet, returned the packet to the locked box, later administered the medications and signed them off as given, and then continued preparing medications for the next resident. When asked when the controlled medication would usually be signed out on the controlled medication log, the RN stated they would usually do it when they take the medication from the packet. The facility policy stated that when the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse by a Known Wanderer
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with known wandering and sexually focused behaviors. One resident with Parkinson’s disease and dementia, who had a BIMS score of 5 and a court-appointed guardian due to legal incapacity, had multiple documented episodes of wandering into other residents’ rooms, entering roommates’ space, and looking for his spouse, which upset other residents. Nursing notes over several months described this resident stumbling into another resident’s room, being threatened by another resident to leave, flooding a bathroom, entering a roommate’s space, and urinating on the floor. Staff also documented that this resident grabbed a nurse’s breast multiple times while laughing and yelling, hit a nurse on the rear end, made sexual remarks to female staff, and tried to get into bed with a neighboring resident while that resident attempted to push him away by shaking and pulling the blanket. Despite these repeated behaviors, the facility did not implement effective care plan interventions for wandering or sexually focused behaviors until shortly before the sexual abuse incident. The care plan did not address these behaviors from admission through multiple documented episodes of room entry and inappropriate sexual contact with staff and attempts to get into bed with another resident. The Administrator later stated that, after one incident, the interdisciplinary team decided to move the resident to another unit, which was identified as the unit where the majority of the facility’s most vulnerable residents with Alzheimer’s disease and dementia resided. The Administrator also stated they believed the resident’s wandering was not repetitive or primarily at night and that the resident was easily redirectable, and acknowledged relying on staff reports rather than reviewing the progress notes that documented multiple wandering incidents. The sexual abuse incident occurred when a CNA, during rounds, turned on the light in a female resident’s room and observed the male resident in bed with her, with his hand down the front of her brief. The female resident had dementia, anxiety, adult failure to thrive, severely impaired cognitive skills for daily decision making, and a court-appointed guardian, and was non-verbal and unable to respond during the post-incident assessment. Camera footage showed that no staff were stationed outside the male resident’s room as care-planned, that he left his room in a wheelchair, looked up and down the hallway, and entered the female resident’s room, remaining there for over an hour before being discovered. The CNA initially left both residents in the bed together while going to get assistance, and neither the CNA nor the LPN who responded used translation tools they typically used to communicate with the male resident, who had a language barrier, to obtain his account of the incident. The female resident’s guardian and spouse later reported they were told only that a man had been found in bed with her and were not informed that his hand had been down her brief.
Failure to Provide Timely Assessment and Intervention for Suspected Stroke
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and ongoing assessment and intervention for a resident who experienced a change in condition suggestive of a stroke. The resident, with a history of transient ischemic attack (TIA), cerebral infarction, encephalopathy, and hypertension, reported symptoms including tingling in the left arm and inability to grasp with the left hand. The nurse documented these symptoms and notified the nurse practitioner (NP), who assessed the resident but did not identify significant changes or initiate further evaluation beyond recommending increased blood pressure monitoring. There was no evidence that the recommended monitoring was implemented or that the resident was reassessed following the initial change in condition. The resident's family reported concerns to the facility about the resident experiencing stroke-like symptoms and missing scheduled neurology appointments. Despite these reports and the resident's new onset of left-sided weakness, the facility did not send the resident for further evaluation or to the hospital, as confirmed by the Director of Nursing (DON), who stated that the expectation was to send residents out immediately for new stroke symptoms. The DON also confirmed that the facility lacked a stroke protocol or policy and that no follow-up was conducted on the resident's change in condition. The therapy department identified a significant change in the resident's functional ability the day after the initial symptoms, but there was still no reassessment or intervention documented. The resident ultimately missed two neurology appointments before being seen by a neurologist, who then sent the resident to the hospital for evaluation of a suspected stroke. Hospital records indicated a new chronic lacunar infarct on imaging. The facility failed to provide appropriate and timely care in response to the resident's change in condition, as well as to ensure attendance at necessary medical appointments.
Failure to Report Resident-to-Resident Abuse and Sexual Misconduct
Penalty
Summary
The facility failed to report a physical and sexual abuse incident involving three residents. A complaint to the State Agency alleged that a male resident entered a female resident’s room naked, got into her bed, and touched her breast, and also attempted to get into the bed of her roommate. A facility-reported incident later described the same male resident entering the room, attempting to get into the roommate’s bed, and exposing and fondling himself next to her in the room. During interviews, the roommate reported that the male resident tried to climb into her bed while she was in it, then stood about four feet away and exposed and fondled himself while wearing only a T-shirt. She said she pushed her call light and waited five to ten minutes for staff to respond, and that six staff members, including an LPN, eventually came into the room. She stated the incident made her feel scared. Another staff interview indicated the male resident had been taking off his clothes, going into patient rooms, and attempting to get into bed with female patients. Record review showed the male resident had intermittent confusion and had been displaying sexually inappropriate behaviors toward patients and staff, including getting into other residents’ beds and being found unclothed. The facility’s investigation concluded no contact occurred between the male resident and the two female residents, although one resident struck him with her shoe while trying to get him away. The facility did not report the incident to the State Agency and police until after learning about it, despite its policy requiring immediate reporting of allegations of abuse and reporting of reasonable suspicion of a crime.
Failure to Ensure Timely Wound Care and Specialist Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely medical appointments and debridement treatments for a resident with a history of gangrene and recent toe amputation, resulting in the worsening of a wound and subsequent hospitalization. The resident, who spoke Korean and had a high cognitive status, was scheduled for follow-up wound care and debridement but was sent to the wrong office for a critical appointment. This error led to a delay of one week before the resident could be seen by the appropriate wound surgeon, during which time the wound deteriorated, ultimately requiring further surgical intervention, including debridement and amputation of an additional toe. The clinical record review revealed that the resident had multiple orders and recommendations for wound care, including specific dressing changes, offloading interventions, and follow-up appointments with wound care specialists and podiatry. Despite these orders, documentation showed missed appointments, lack of timely follow-up, and a failure to implement recommended treatments such as vancomycin, which was noted in progress notes but never ordered or administered. Additionally, the resident was noted to be performing self-care on the wound, which was identified as delaying healing, and there was insufficient use of translation services to address the resident's language barrier, despite the availability of such resources. Interviews with facility staff, including wound nurses, the DON, and the unit clerk, confirmed lapses in communication, scheduling, and follow-up. The unit clerk acknowledged sending the resident to the wrong location, and both wound nurses were unclear about the specifics of the resident's care and did not utilize available translation services. The DON was aware of the language barrier and the resident's self-care but did not ensure the use of interpreter services. Facility policies required weekly evaluation of skin alterations and prompt response to changes in condition, but these were not consistently followed, contributing to the resident's decline and need for hospitalization.
Failure to Provide Supervision During Resident Transportation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, convulsions, and blindness in one eye, and who was assessed as having moderately impaired cognition and lacking capacity to make reasoned medical decisions, was sent unaccompanied to multiple medical appointments. The resident's clinical record indicated a need for 24-hour care and supervision, and a physician's statement confirmed the resident's inability to provide informed consent or medical history. Despite these documented needs, the resident was transported alone to appointments, and on at least one occasion was left in the lobby of a doctor's office without a caretaker from the facility. Interviews with facility staff revealed inconsistent practices and a lack of clear procedures regarding which residents required staff accompaniment to appointments. The unit clerk stated that, until recently, staff did not accompany residents, and decisions about competency were made informally. The DON acknowledged that the resident should not have been allowed to leave the facility alone, and the administrator recognized the concern regarding the resident's care plan for 24-hour supervision not being followed during transportation to appointments.
Failure to Identify and Respond to Change in Condition and Inadequate Physician Notification
Penalty
Summary
The facility failed to identify and appropriately respond to significant changes in condition for two residents, resulting in serious negative outcomes. For one resident with a history of urinary retention and recent hospitalization, there was a delay in scheduling a required urology follow-up, despite provider orders for timely consultation. The resident exhibited symptoms such as hematuria and pain with urination, and was started on antibiotics for a urinary tract infection (UTI). However, the antibiotic prescribed was not effective against the identified organism, as shown by culture and sensitivity results, yet the ineffective medication continued to be administered. Staff did not document or address additional symptoms such as sore throat, poor oral intake, and mental status changes, and failed to recognize or act upon a significant decline in the resident's condition, including not eating for two days and exhibiting confusion and weakness. The resident was only sent to the hospital after family intervention, where they were diagnosed with UTI, pneumonia, sepsis, and subsequently died from septic shock secondary to UTI and pneumonia. For another resident admitted with a femur fracture, pulmonary hypertension, and heart failure, the facility did not adequately monitor or respond to changes in vital signs and mental status. The resident experienced episodes of low blood pressure, bradycardia, and hypoglycemia, with documentation of lethargy and delayed responses. Despite these changes, there was no documentation that the physician was notified. When the resident's family expressed concern about cardiac issues and requested discharge against medical advice, the facility delayed implementing a STAT EKG order and did not complete the test before the resident was transferred to the hospital for respiratory distress. There was also a lack of documentation regarding the assessment and follow-up of the resident's cardiac and respiratory symptoms prior to transfer. Facility policy required staff to monitor and evaluate residents for changes in condition and to notify the physician team for direction when such changes were identified. In both cases, the facility failed to follow this policy, resulting in delayed recognition and treatment of acute medical issues, lack of appropriate physician notification, and insufficient documentation and follow-up of significant clinical changes.
Failure to Identify and Respond to Change in Condition, Medication Administration, and Documentation Deficiencies
Penalty
Summary
Facility staff failed to ensure timely identification, assessment, and reporting of a resident's change in condition, resulting in multiple hospitalizations. The resident, who had a history of fracture, repeated falls, severe malnutrition, dysphagia, and weight loss, exhibited ongoing symptoms such as poor appetite, gagging, and dry heaving. Despite family concerns and reports of aspiration and emesis, staff did not perform or document comprehensive assessments or obtain vital signs prior to significant events, including hospital transfers. Documentation revealed that staff relied on secondhand information rather than direct assessment, and there was no evidence of timely physician notification or accurate evaluation of the resident's status during these episodes. The facility also failed to follow professional nursing standards for medication administration and monitoring. Blood pressure readings were not consistently obtained before administering antihypertensive medications, and there were instances where medications were held or given without appropriate clinical justification or documentation. Additionally, the facility did not implement or document physician orders for supplemental oxygen and intravenous therapy as required. Oxygen was administered without a physician order, and there was no documentation explaining the rationale, timing, or physician notification regarding changes in oxygen delivery or the resident's elevated heart rate. Nursing skilled notes were incomplete or inaccurate, with missing assessments on key dates and discrepancies between documented care and the resident's actual needs. Orders for IV fluids were not carried out, and abnormal vital signs, such as critically low blood pressure, were not reported to the physician. The lack of timely transfer to a higher level of care, incomplete documentation, and failure to follow facility policies contributed to the resident's repeated hospitalizations and ultimately, the resident's death. Interviews with facility leadership confirmed gaps in assessment, documentation, and adherence to policy.
Plan Of Correction
F684 - Quality of Care It is the practice of the facility to ensure that quality care is provided following the fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Element 1: Resident R402 no longer resides in the facility. Element 2: Residents residing in the facility who have a change in condition have the potential to be affected by the cited practice. The facility has completed audits and reviews of current residents pertaining to any of the cited practices listed below. An audit was conducted to ensure that residents with a change of condition have appropriate evaluation, monitoring, documentation, and physician notification. An audit was conducted on residents who have blood pressure medications to ensure their vital signs were obtained and orders followed as written. A full house sweep was conducted of resident rooms for oxygen and IV equipment and was reconciled with resident active orders for oxygen and IV medications. An audit of residents recently transferred to acute care since the date of survey exit (4/10/2025) was conducted to ensure that acute care transfer was completed in a timely manner in accordance with the residents' needs. If any of the above noted areas were found to be out of compliance, they were corrected immediately with all necessary parties notified. Element 3: A QAPI meeting was held by the interdisciplinary team who reviewed the change of condition policy, medication pass policy, physician orders policy, and the resident transfer policy, to which all were deemed appropriate for use. Facility nurses will be reeducated on the policies with a focus on changes in condition and completion of documentation of the change in condition. Element 4: The DON/Designee will audit for resident changes of condition twice a week for 4 weeks, then monthly for 3 months. Audits will include but are not limited to timely identification, accurate assessment, monitoring, and documentation of the resident's change in condition, documentation and implementation of physician orders, and timely transfers to a higher level of care when necessary. Residents will be discussed within the morning IDT meetings Monday-Friday. The results of the audits will be reviewed during the monthly QAPI meeting. Any areas found to be out of compliance will be corrected immediately with physician and family notifications completed as appropriate. Element 5: The director of nursing is responsible for ultimate compliance. Compliance date of May 6, 2025.
Failure to Timely Assess, Monitor, and Intervene for Severe Weight Loss and Malnutrition
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, dysphagia, and abnormal weight loss was admitted to the facility following a hospital stay. Upon admission, the resident's weight was recorded as the same as the hospital discharge weight, and the initial nutrition assessment noted a significant weight loss of 30 pounds over the prior three months. Despite this, the facility failed to identify or address a further weight loss of 4.29 pounds within the first week of admission, and no interventions were implemented to prevent additional weight loss for more than two weeks. The resident continued to experience poor appetite, nausea, and difficulty tolerating the prescribed diet, but interventions such as medication adjustments and dietary supplements were delayed or not implemented in a timely manner. Communication and coordination among the facility's interdisciplinary team were lacking. Requests for a gastroenterology (GI) referral for possible PEG tube placement were not followed up promptly, and there was no documentation of timely notification to the physician or action taken regarding the resident's and family's expressed wishes for a feeding tube. The registered dieticians were unaware of the resident's request for a PEG tube and did not document or address the ongoing nutritional concerns. Additionally, the facility failed to consistently monitor the resident's intake, did not obtain a new weight upon readmission from the hospital, and did not ensure that ordered dietary supplements were administered as documented in the medical record. Throughout the resident's stay, there was a breakdown in communication and oversight, with the registered dieticians and nursing staff failing to collaborate effectively or escalate concerns to administration. The resident experienced a severe weight loss of 13.27% within two months, was hospitalized twice for acute changes in condition related to poor intake and dehydration, and ultimately died with severe calorie malnutrition listed as a cause of death. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's nutritional status, interventions, and care planning, as well as failures to follow facility policy on monitoring and addressing nutritional risk.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance It is the practice of the facility to ensure that resident maintains acceptable parameters of nutritional status such as usual body weight or desirable body weight range and electrolyte balance, unless the residents' clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Element 1: Resident 402 no longer resides in the facility. Element 2: Residents who live in the facility can be affected by the deficient practice. An audit was conducted for residents with recommendations for Gastrointestinal referrals to ensure that they have a physician order for the consult and documentation that an appointment for the consult was scheduled with the Gastrointestinal specialist. Current residents in the facility had their weights reviewed to be sure that the most recent and accurate weights were reported to the Dietitian. An audit was completed by the Dietitian of residents with significant weight loss to ensure physician notification was documented and interventions are in place to address weight loss. Current residents admitted within the last 30 days will be reviewed to ensure admission weights were obtained and recorded in their medical records. Any resident admitted within the last 30 days who does not have a weight recorded in the medical record will be weighed and documented in the medical record. Newly admitted residents will be reviewed by the dietitian to ensure weekly weights are completed and documented for 4 weeks and then as directed by the dietician. The IDT Team will have a nutritional at-risk meeting weekly to review residents at nutritional risk, residents with significant weight loss, and residents with gastrointestinal referrals, to ensure physician notification has been completed and documented, and appropriate nutritional interventions are in place. Element 3: The interdisciplinary team reviewed the Consultations policy and deemed it appropriate. The facility unit clerks and nurse managers were educated on the Consultations policy. The interdisciplinary team reviewed the weight policy and deemed it appropriate for use. The nursing staff and Dieticians were educated on the policy. The interdisciplinary team reviewed the Monitoring Adequate Nutrition and Hydration Status policy and deemed it appropriate for use. The dietitians were educated on the policy. Element 4: The director of nursing/designee will audit residents with recommendations for gastrointestinal referrals to ensure physician orders and appointments are in place weekly for 4 weeks and then monthly for 3 months. The dietitian will audit newly admitted residents to ensure weights are obtained upon admission and weekly for 3 additional weeks and that current residents' ordered weights/reweights are completed and documented. The administrator/designee will audit residents with significant weight loss to ensure physician notification and nutritional interventions were implemented weekly for 4 weeks then monthly for 3 months. The results will be reviewed monthly in QAPI for 3 months and then PRN if no trends are noted. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of a lumbar vertebra fracture and recent acute distal tibia fracture did not receive care according to their established plan, which required two-person assistance for bed mobility, toileting, and transfers. On the date of the incident, an agency CNA provided incontinence care to the resident alone, despite the care plan specifying the need for two staff members. During this care, the resident's right leg came off the mattress and made contact with the floor, which the resident reported caused pain and was followed by a new diagnosis of a distal tibia fracture. The resident, who was cognitively intact and dependent on staff for mobility, described that aides often lifted the pad underneath them to turn or move them, and on this occasion, the CNA moved too quickly, resulting in the leg slipping off the bed. The CNA involved stated that they were not informed of the two-person assist requirement and that it was their first time working at the facility. The facility's documentation and investigation revealed that only one staff statement was obtained, and there was no evidence of staff education or additional interviews with other staff or residents regarding the incident. The facility's own investigation and interviews with the Administrator and DON confirmed that the resident's care plan had not changed before or after the incident and that the resident always required two-person assistance for safety. The lack of adherence to the care plan and insufficient communication to agency staff about resident-specific care needs directly led to the resident sustaining a serious injury during routine care.
Plan Of Correction
F689 Free of Accident Hazards/Supervision/Devices It is the practice of the facility to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated. Element 2: Residents residing in the facility requiring two persons assist for bed mobility are at risk. An audit was completed by the DON/designee of all residents requiring 2 persons assist with bed mobility to ensure their Kardex and care plan were appropriate to ensure adequate support to prevent accidents. Element 3: The interdisciplinary team reviewed the ADL policy and deemed it appropriate for use as written. Licensed nurses and nursing assistants (to include agency staff) will be educated on the ADL policy with emphasis on following Kardex/Care plan when providing assistance with bed mobility and ADL care. In-services will be ongoing as needed. Element 4: The administrator/designee will conduct random audits for residents requiring 2 people to assist with bed mobility to ensure the plan of care was followed weekly for 4 weeks then monthly for three months. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Accurately Document and Implement DNR Order
Penalty
Summary
A deficiency was identified when the facility failed to ensure consistent implementation and documentation of a Do Not Resuscitate (DNR) order for a resident with dementia and a malignant neoplasm of the prostate. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, had a DNR order signed by both the resident and their physician. However, the electronic medical record (EMR) demographic page incorrectly listed the resident as "Full code," meaning cardiopulmonary resuscitation (CPR) would be performed in the event of cardiac arrest. During interviews, both a nurse and a social worker reviewed the resident's EMR and initially reported the resident as "Full code." It was only after further review that the social worker discovered the signed DNR order in the record and acknowledged the discrepancy. The social worker was unaware of how the error occurred and indicated the need for correction to reflect the resident's actual wishes as documented in the DNR order. Facility policy requires that a fully executed DNR form be uploaded into the resident's electronic health record and that the physician's order for DNR be entered so the code status is accurately displayed in the chart header and face sheet. In this case, despite the presence of a valid DNR order, the resident's code status was not accurately reflected in the EMR, leading to confusion among staff regarding the resident's end-of-life care preferences.
Plan Of Correction
578 Request/Refuse/Discontinue treatment; Formulate Adv Dir It is the practice of the facility to ensure the resident right to request, refuse and/or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advance directive. Element 1 Resident 408 remains in the facility and has been unharmed by the deficient practice. The resident's code status order has been corrected to DNR (do not resuscitate). Element 2 Residents residing in the facility who have signed a DNR are at risk. An audit was completed by the DON/designee of all residents with a signed DNR to ensure their physician order and demographics page match. The plan of care has been reviewed and updated by the interdisciplinary team. Element 3 The interdisciplinary team reviewed the advanced directive policy and deemed it appropriate for use as written. The licensed nursing staff and social work staff were educated on the policy. Element 4 The administrator/designee will audit all new admits/readmits to ensure appropriate advance directives orders and documentation is in place weekly x4 and monthly x3. Element 5 The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Protect Resident from Physical Abuse by Staff Member
Penalty
Summary
A facility failed to protect a resident's right to be free from physical abuse by a staff member. The incident involved a resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who required assistance with most activities of daily living and had an intact mental status as indicated by a BIMS score of 14. The resident reported that during the early morning hours, while receiving incontinence care from an assigned nurse, she accidentally kicked the nurse out of fear of falling. In response, the nurse allegedly hit the resident on the left upper arm and told her she would have to wait for the day shift to finish her care. The facility's investigation included interviews with both the resident and the nurse involved. The resident consistently reported the incident, stating she felt safe in the facility otherwise and requested not to have the same nurse assigned to her in the future. The nurse denied the allegations, claiming she did not provide any ADL care to the resident during her shift and only interacted with her for medication administration. The nurse also stated the resident was confused and denied any physical contact or awareness of abuse during her shift. Despite the nurse's denial, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse had violated work rules related to confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward a resident. The nurse continued to work in the facility after the incident, and the disciplinary action document reflected the substantiated abuse and neglect.
Plan Of Correction
F600 Free from Abuse and Neglect It is the intent of the facility to ensure that all alleged violations are thoroughly investigated to prevent further potential abuse. Element 1: Resident 404 does not reside within the facility. Nurse M is no longer working at the facility. Facility staff were re-educated on Abuse Policy. Element 2: All residents residing in the facility can be affected by the cited practice. Residents with BIMS score of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the facility managers were educated on disciplinary actions and the administrator and DON educated with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 4: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident who sustained a fracture of the tibia and fibula while receiving care from an agency CNA. The incident took place during a brief change, when the resident's right leg came off the mattress and hit the floor, as described by the resident. The resident reported pain and fear following the incident, but did not immediately notify the nurse due to concerns about the CNA's reaction. The resident later informed a nurse the next day, and subsequently reported increased pain to the Nurse Manager several days later. The clinical record indicated that the resident had a history of orthopedic issues, including a previous lumbar vertebra fracture and was dependent on staff for bed mobility and transfers, requiring two-person assistance and a mechanical lift. Despite the resident's complaints of pain and the change in condition, the Nurse Manager was not notified until several days after the incident, and the Administrator (Abuse Coordinator) was not informed until after the x-ray confirmed the fracture. The facility's own documentation confirmed that the resident's complaints were known to nursing staff prior to the Administrator being notified. The facility's policy required immediate reporting of all allegations of abuse, neglect, or injuries of unknown source to the Administrator and State Survey Agency, but this was not followed. The delay in reporting was acknowledged by facility leadership during interviews, with the Administrator noting that the Nurse Manager should have reported the concern when first made aware. The failure to report the incident in a timely manner constituted noncompliance with federal requirements for reporting alleged violations.
Plan Of Correction
F609 Reporting of Alleged Violations It is the practice of the facility to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the events do not involve abuse and do not result in bodily injury, reporting is required not later than 24 hours to the administrator and other officials in accordance with state law through established procedures. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and she. The contracted CNA involved in the incident no longer works at the facility. All residents residing in the facility can be affected by this cited practice. Residents with BIMS scores of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS scores of 11 or lower will also be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 2: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the administrator and DON educated staff with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 3: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks, then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance with the abuse process, including timely reporting and investigation. Element 4: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Investigate Abuse Allegations and Prevent Further Resident Exposure
Penalty
Summary
The facility failed to thoroughly investigate an initial injury of unknown origin and an allegation of mistreatment for one resident, as well as failed to prevent further access between a resident and an employee with confirmed abuse findings. Specifically, the facility did not complete a comprehensive investigation into the circumstances surrounding the injury and mistreatment, as required by their abuse prevention policy. The policy mandates timely, thorough, and objective investigations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with relevant knowledge, and providing complete documentation of the investigation. Additionally, the facility did not ensure the protection of a resident by allowing continued access to an employee who had confirmed abuse findings, contrary to the policy that requires immediate removal of the alleged perpetrator from the facility and schedule pending the outcome of the investigation. These failures were identified during the review of two specific intakes and involved at least two residents, one of whom had an injury of unknown origin and another who was exposed to an employee with a history of abuse.
Plan Of Correction
F610 Investigate/Prevent/Correct Alleged Violation It is the practice of the facility, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and the contracted CNA involved in the incident no longer works at the facility. Element 2: Residents with allegations of abuse have the potential to be affected. Investigation files of those residents with open investigations have been reviewed to validate a thorough investigation was conducted to include implementation of corrective measures to prevent further potential abuse. No additional instances as identified in the citation were identified. Residents with BIMS score of 12 or higher were interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility managers were educated on the abuse policy with an emphasis on completing a full and thorough investigation and on corrective actions to prevent further potential abuse. The Quality Assurance Consultant will in-service Unit Manager and Director of Nursing regarding maintaining all evidence of an investigation. Element 4: Audits on allegations of abuse will be completed weekly by the Administrator/designee to validate a full and thorough investigation was completed, corrective actions were taken to prevent further potential abuse, and that evidence of the investigation is maintained. Results of the audits and interviews will be submitted to the QAPI committee for further review and recommendations. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Respond Promptly and Provide Timely ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to promptly respond to a dependent resident who was continuously yelling for assistance. Upon observation, three employees, including a CNA, a Nurse Manager, and a Unit Clerk, were seated at the nursing desk and did not respond to the resident's loud calls for help. Other residents and visitors in the area expressed concern about the yelling, but no staff intervened until much later. When the resident's room was entered, the individual was found poorly positioned in bed, with their head and lower extremities nearly off the mattress, and the call light was out of reach. The resident, who was incontinent and unable to reposition themselves, stated they needed to be changed and was found to have a wet brief. The call light was only activated by the surveyor, and staff did not respond until several minutes later. Interviews with staff revealed a lack of timely incontinence care and inadequate attention to the resident's needs. The assigned CNA confirmed that no incontinence care had been provided since the start of the shift, and the Unit Clerk, who was also a CNA, acknowledged the resident was wet and improperly positioned. Staff attributed the resident's yelling to behavioral issues and did not take immediate action, despite care plans indicating the need for call lights to be within reach and regular assistance with toileting and hygiene. Documentation for incontinence care was also incomplete for the day in question. The resident involved had a history of dementia, behavioral disturbances, incontinence, and required moderate assistance with activities of daily living. Care plans included interventions for communication, safety, and elimination needs, but there were no specific interventions for the resident's yelling behavior. Facility policy required repositioning of dependent residents at least every two hours, but this was not observed. The failure to respond promptly, provide timely incontinence care, and ensure proper positioning and access to the call light led to the identified deficiency.
Plan Of Correction
F0677 ADL Care Provided for Dependent Residents It is the practice of the facility to ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Element 1: Resident 410 remains in the facility and has been assisted with repositioning, ADL care, and call light placement at the time of the survey. The plan of care was reviewed and updated. Element 2: Residents who need staff assistance and/or positioning devices for proper positioning have the potential to be affected by the cited practice. An audit of residents requiring staff assistance and/or positioning devices for proper positioning was completed, and their care plans/Kardex were reviewed and updated, if applicable. An audit was completed to ensure call lights were within reach and residents who require staff assistance and/or positioning devices for proper positioning were in place. Element 3: The interdisciplinary team reviewed the "Activities of Daily Living" (ADL's), call light, incontinence care, and repositioning policies and procedures and deemed them appropriate for use as written. The facility licensed nurses and nursing assistants have been educated on the above policies. Element 4: The DON/designee will complete random audits weekly to ensure residents requiring staff assistance and/or positioning devices are properly positioned. The IDT team will complete random audits weekly to ensure call lights are within reach. The IDT team will complete random audits weekly to ensure residents calling out for assistance are responded to. Audits will be completed weekly for 4 weeks, then monthly for 3 months. Any deficient practice will be corrected/updated immediately. The results will also be taken to the QAPI meeting. Element 5: The Administrator is responsible for compliance: date of compliance May 6, 2025.
Failure to Follow Policy for Decision-Making Capacity Assessment and Documentation
Penalty
Summary
Facility staff failed to follow their own policy regarding decision-making capacity assessments for a resident admitted with multiple complex diagnoses, including a right pubis fracture, repeated falls, severe protein-calorie malnutrition, dysphagia, and abnormal weight loss. Concerns were raised by the resident's daughter about the resident's cognition, prompting a discussion with the Social Work Director about the need for a competency evaluation and the possible activation of the resident's Durable Power of Attorney (DPOA). However, this discussion was not documented in the progress notes, and the psychiatric consult to determine capacity was not completed until several weeks later. The evaluation for decision-making capacity was ultimately performed by a contracted physician, who determined the resident lacked capacity due to delirium and encephalopathy. The required facility form, "Physician Statement of Capacity for Medical Treatment and Decisions," was signed by this physician as the second examiner, although they were actually the first to evaluate the resident. The attending physician signed the form the following day, despite the resident having already been transferred to the hospital and not being present in the facility. There was no documentation in the medical record that the attending physician or any other attending clinicians had evaluated the resident for capacity. Additionally, the original capacity form was not found in the resident's medical record, and staff could not provide it when requested. The facility's policy required that two physicians determine incapacity, with thorough examinations and proper documentation uploaded to the resident's chart. These steps were not followed, as only one physician evaluated the resident, and the documentation process was incomplete and inconsistent with facility policy.
Plan Of Correction
F 745 Provision of Medically Related Social Services It is the practice of the facility to ensure that all residents receive medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow the policy on capacity decision making for 1 of 4 residents. Element 1 R402 no longer resides at the facility. Element 2 Residents that require a capacity evaluation have the potential to be affected by the cited practice. An audit was completed for residents that have had a capacity evaluation completed to ensure the policy was followed and all appropriate paperwork and documentation is in place. Any deficiencies noted in the audit were immediately corrected. Element 3 The Interdisciplinary Team reviewed the Decision-Making Capacity Policy and deemed it appropriate. All social service staff and the attending physicians have been educated on the policy and procedure with emphasis on ensuring capacity evaluations are being completed timely and with appropriate documentation. Element 4 The Social Service Director, or designee, will complete random audits on residents with a request for a capacity evaluation weekly x 4 weeks then monthly x3. Element 5 The administrator is responsible for compliance with a compliance date of May 6th, 2025.
Failure to Conduct Thorough Investigation After Resident Injury
Penalty
Summary
A resident with a history of lumbar vertebra fracture and requiring two-person assistance with bed mobility sustained a distal tibia and fibula fracture of unknown origin while receiving care from an agency CNA. The resident reported that the aide moved them too quickly during a brief change, causing their right leg to come off the mattress and hit the floor. The resident did not immediately report the incident to nursing staff due to fear, but later informed a nurse manager after experiencing increased pain. The clinical record indicated the resident was alert, cognitively intact, and had ongoing mobility and incontinence needs. The facility's investigation into the incident was incomplete. Only one witness statement was obtained, from the agency CNA involved, who denied the resident's leg hit the floor and stated the resident was already complaining of pain. There was no documentation of interviews with other staff or residents, and no evidence that all relevant parties were questioned. The investigation documents provided to the State Agency and reviewed during the survey were the same, lacking additional statements or supporting evidence. During interviews with facility leadership, it was confirmed that the investigation did not include comprehensive interviews with nursing staff or like-residents, and there was no documentation of education or disciplinary action for staff involved. The administrator acknowledged that the aide did not follow the plan of care, which required two-person assistance, and that the investigation was incomplete. No further documentation or follow-up was provided by the end of the survey.
Failure to Remove Staff from Resident Care Following Substantiated Abuse Allegation
Penalty
Summary
A resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who was cognitively intact according to a BIMS score of 14, alleged that during the midnight shift, a nurse physically abused her while providing incontinence care. The resident reported that she accidentally kicked the nurse out of fear of falling, after which the nurse hit her on the left upper arm and told her she would have to wait for the day shift to finish her care. The resident expressed feeling safe in the facility overall but requested not to have the same nurse assigned to her in the future. The facility conducted an investigation into the incident, interviewing both the resident and the nurse involved. The nurse denied the allegations, stating she did not provide any ADL care to the resident and only interacted with her during medication administration, further claiming the resident was confused. Despite this, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse received a final written warning for confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward the resident. Despite the substantiated abuse allegation and the resident's request, the nurse continued to be assigned to the resident and provided care, including medication administration, on multiple occasions after the incident. The administrator was unaware that the nurse had continued to care for the resident and acknowledged that this was not in line with facility policy, which states that staff involved in abuse allegations should be immediately removed from contact with the resident pending investigation. The facility's own abuse policy requires immediate protective actions to prevent further harm, which were not followed in this case.
Deficiency in Mechanical Lift Maintenance and Availability
Penalty
Summary
The facility failed to provide safe, operational mechanical lifts for three residents, leading to significant issues with resident transfers and mobility. The mechanical lifts were reported to be in disrepair, with batteries frequently not holding a charge, which left residents unable to leave their rooms for activities or exercise. One resident expressed frustration over being unable to maintain their routine of getting up multiple times a week due to the lack of operational lifts. The resident also raised concerns about the potential risks in case of an emergency, such as a fire, where they would need to be evacuated from their bed. Observations and interviews revealed that the facility had issues with the availability and maintenance of mechanical lifts. Certified Nurse Aides reported difficulties in finding charged batteries and operational lifts, which impacted their ability to provide timely care to residents. One resident was observed being transferred with a lift that had medical tape at the anchor, indicating potential safety concerns. Another resident reported discomfort and safety concerns due to the use of an inappropriate lift model for their size, and instances where transfers were conducted with only one staff member instead of the required two. The Maintenance Director acknowledged the issues with the lifts and batteries, citing that the vendor had taken batteries for refurbishment and that routine maintenance had not been conducted due to unpaid bills. The facility's process for reporting maintenance concerns was also found to be inadequate, as staff often did not use the electronic system to log repair needs, leading to delays in addressing issues. During a tour of the facility, it was observed that there were only three operational lifts and no backup batteries available, which further exacerbated the problem of ensuring safe and timely resident transfers.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the resident council meetings were promptly documented, investigated, tracked, and resolved. During a group meeting, four residents expressed that their concerns raised in the monthly resident council meetings were not addressed or resolved in a timely manner. One resident specifically noted that while concerns were brought up, no resolution was provided. A review of the resident council meeting minutes for September, October, and November 2024 revealed concerns with nursing services. However, the facility's administrator admitted to having no documentation showing that these concerns were addressed or resolved. Additionally, the Activities aide confirmed that while they kept documentation of concerns, there was no grievance resolution form for the nursing services concerns documented in the September meeting minutes.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure services met professional standards of practice for four residents. For one resident, R2, there was a discrepancy in the documentation of their status. Although R2 had been discharged to the hospital on 12/6/24, progress notes were incorrectly documented by an LPN, indicating that R2 was still present in the facility. The LPN responsible for the notes was assigned to a different unit and mistakenly charted on the wrong resident, leading to inaccurate records. Another resident, R45, was observed with a medical measuring cup containing an orange liquid and ointment packets left on their over-bed table. The resident believed the liquid was medication for their bowels. The DON confirmed that medications should not be left at the bedside if a resident refuses them, indicating a lapse in medication administration protocol. For resident R13, a stool sample was mishandled and incorrectly labeled, resulting in a delay in testing for C-Diff as per physician orders. This error led to an extended isolation period for the resident. Additionally, for R308, a urine specimen was sent without proper patient identifiers, rendering it untestable. There was no documentation of communication with the physician regarding the invalid sample, highlighting a failure in the facility's infection control and communication processes.
Discrepancies in Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of controlled substances for a resident, identified as R258, who was admitted with diagnoses including intraspinal abscess, meningitis, and rheumatoid arthritis. The resident was cognitively intact, as indicated by a perfect score on a Brief Interview for Mental Status assessment. A physician had ordered Hydromorphone 2 mg, to be administered as needed for pain, with a specific instruction to give two tablets every four hours. However, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Form and the Medication Administration Record (MAR) for this medication. On several occasions, tablets were documented as being removed from the resident's supply without corresponding documentation on the MAR indicating that the medication was administered. Specifically, on multiple dates, tablets were removed but not recorded as given, and there were instances of times being altered on the MAR. Additionally, there was no documentation of any medications being wasted. The Director of Nursing was informed of these discrepancies, which involved eight tablets of Hydromorphone that were unaccounted for in terms of administration to the resident.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure medications were stored appropriately and in a safe and sanitary manner, as observed in three of four medication carts and one treatment cart. During an inspection, a coffee cup was found in a medication cart drawer, and several medications, including Lispro Insulin and Brimonidine Tartrate eye drops, were found without open dates, indicating they had been used but not properly labeled. Additionally, another medication cart contained crushed pill debris, and several medications, including a Lantus SoloStar Insulin Pen, a Fluticasone Salmeterol inhaler, and a Spiriva inhaler, were also found undated, confirming they had been opened and used without proper labeling. Furthermore, an unattended and unlocked treatment cart containing various wound care creams and medications was observed, which was later confirmed by the Director of Nursing (DON) to be against the facility's policy. The DON acknowledged that coffee should not be in a medication cart and that all medications should be dated when opened. These observations highlight lapses in the facility's adherence to its medication storage policies, potentially compromising the safety and efficacy of the medications administered to residents.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices related to transmission-based precautions for two residents, R159 and R6, which could potentially lead to the spread of infection. For R159, who was on contact precautions due to a diagnosis of Candida auris, a CNA was observed exiting the resident's room without performing hand hygiene and later re-entering without donning any PPE. The CNA was unaware of the specific precautions required and had not been adequately informed about the differences between transmission-based precautions and enhanced barrier precautions. The Director of Nursing acknowledged the issue and indicated that the Infection Preventionist, who was new to the role, was responsible for infection control. For R6, who was on both enhanced barrier precautions and contact precautions due to an infection requiring IV antibiotics, there was confusion regarding the signage and the precautions to be followed. An unidentified staff member was observed in the resident's room without PPE, and a phlebotomist was seen performing a blood draw without adequate PPE and with a lab cart containing supplies for multiple residents. The Infection Preventionist admitted to being unsure about the correct procedures and deferred to corporate decisions regarding the conflicting signage. The facility's policies and procedures were not adequately followed, as evidenced by the lack of proper PPE use and hand hygiene by staff members. The Infection Preventionist and other staff members were not fully aware of the necessary precautions, leading to inconsistent practices and potential risks of infection transmission. The facility's lab contract required compliance with applicable standards and laws, which was not observed during the survey.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity of its residents, as evidenced by multiple incidents involving residents R259 and R50. R259, who was cognitively intact and required assistance for toileting, reported that a staff member instructed them to urinate in their brief instead of being assisted to the bathroom. Despite informing several staff members, including the Unit Manager, no action was taken to identify the responsible staff member or address the issue. The Director of Nursing was unaware of the incident, indicating a lack of communication and follow-up within the facility. Resident R50, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed multiple times without proper clothing, only wearing a brief or a gown. The facility's staff, including the Social Worker and Certified Nursing Assistant, confirmed that R50 had no personal clothing at the facility. Despite claims that R50 preferred not to wear clothes, there was no documentation or evidence to support this, as R50 had never been provided with clothing during their stay. The facility failed to ensure R50's privacy and dignity by not providing appropriate clothing or ensuring privacy measures were in place. Additionally, during a group meeting, three anonymous residents reported feeling disrespected by the staff, indicating a broader issue of dignity and respect within the facility. These findings highlight systemic issues in the facility's approach to maintaining resident dignity, as evidenced by the lack of appropriate responses to resident concerns and inadequate measures to ensure privacy and respect.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure a resident's right to personal privacy during a medical procedure. On December 11, 2024, at 9:18 AM, a resident was observed in their room undergoing a blood draw while the privacy curtain and door were left open, allowing the procedure to be visible from the hallway. This lack of privacy was confirmed by the Unit Manager who was present outside the room. When questioned, the phlebotomist performing the procedure did not provide a response regarding the failure to ensure privacy. The resident involved had been admitted with a diagnosis of Methicillin-susceptible Staphylococcus aureus (MSSA). The facility was unable to provide a policy on privacy during care when requested by the surveyors.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to properly document and communicate the transfer of a resident to the hospital, resulting in a deficiency. The resident, who was cognitively intact and had diagnoses including diabetes, depression, and dementia, was sent to the hospital on 12/6/24. However, the facility did not complete the necessary transfer documentation, such as the hospital transfer form, which should have included critical information like the resident's status, contact information, and recent medical data. Additionally, the resident was still listed as active in the facility's records, and progress notes inaccurately documented the resident as being present in the facility after the transfer date. Interviews with facility staff, including an RN and the DON, revealed a lack of communication and oversight in the discharge process. The RN was unaware of the resident's transfer status and the absence of a transfer form, while the DON acknowledged the oversight and the need for proper documentation. The facility's policy on transfers and discharges, which outlines the required steps and information for a hospital transfer, was not followed, leading to the deficiency identified during the survey.
Failure to Follow Admission Medication Order
Penalty
Summary
The facility failed to ensure an admission medication order was followed for a resident who was admitted requiring nursing care and rehabilitation after a fall resulting in spinal and elbow fractures. The resident had a medical history of hypertension, anxiety, asthma, and muscle weakness, and was cognitively intact with a BIMS score of 14/15. Upon admission, pharmacy recommendations indicated that the resident should not continue on Trelegy Ellipta, an inhaled medication. However, the Director of Nursing (DON) confirmed that the resident continued to receive Trelegy Ellipta, and there was no confirmation that the physician was informed of the pharmacy's recommendation. The facility's policy required new admission orders to be reviewed with the resident's physician for any changes or clarifications, which was not adhered to in this case.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to adequately assess and implement treatment orders for pressure ulcers for two residents, leading to deficiencies in their care. Resident #38 was admitted for nursing care and rehabilitation following fractures and was cognitively intact. Despite an order for a wound care consult on 10/25/24, a skin assessment on 11/25/24 identified heel breakdown, which was not communicated to the wound care nurse until 12/3/24. During this time, the resident's husband was applying his own treatment to the heels, which was not in line with the prescribed care. Resident #39, who was dependent on staff for most activities of daily living, had a stage III pressure ulcer on the sacral region. The treatment plan for this ulcer was not consistently followed, with missed applications of prescribed treatments on several dates in November 2024. The wound care coordinator and the nurse practitioner had discrepancies in the treatment plan, with the coordinator unaware of changes in the treatment orders. This lack of communication and adherence to the treatment plan resulted in the resident not receiving the appropriate care for their pressure ulcer. The facility's failure to ensure proper communication and implementation of treatment orders for pressure ulcers resulted in inadequate care for both residents. The wound care nurse and other staff did not consistently follow the prescribed treatment plans, leading to a lack of timely and appropriate interventions. This deficiency highlights the need for improved communication and adherence to treatment protocols to prevent further deterioration of residents' conditions.
Failure to Conduct Timely CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs), identified as CNA 'L' and CNA 'P', had their skills and competencies evaluated in a timely manner. CNA 'L', hired on April 22, 2011, and CNA 'P', hired on May 14, 2012, both had their most recent skills/competency evaluations completed on July 6, 2023. This indicates that their evaluations were not conducted annually as required. The In-Service Director, who assumed the role in October 2024, acknowledged the lapse and confirmed that the evaluations should be done annually. The facility's policy documentation provided for skills/competencies included only a blank copy of the CENA New Hire and Annual Skills Checklist, further highlighting the deficiency in maintaining up-to-date evaluations.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory diagnostics were completed for two residents, leading to a deficiency in providing timely and quality laboratory services. Resident 47, who had diagnoses including tracheostomy, end-stage renal disease, and cerebral infarction, was ordered to have weekly complete blood count (CBC) and comprehensive metabolic panel (CMP) tests starting from November 18, 2024. However, only one set of results was available with a collection date of December 2, 2024, indicating that the other weekly tests were not conducted as ordered. Similarly, Resident 52, who had severe cognitive impairment and diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had a physician-ordered CBC with differential on November 25, 2024, due to leukocytosis. The medical record did not contain any results for this test. The Director of Nursing (DON) was unaware of the missing lab order for Resident 52 due to an incorrect entry in the electronic medical record, which categorized the order incorrectly. The DON confirmed that the weekly labs for Resident 47 were also not completed, leading to the deficiency identified during the survey.
Failure to Communicate with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration with hospice services for a resident who was under hospice care. The resident, who was admitted with multiple medical diagnoses including cerebral infarct, hypertension, atrial fibrillation, right-sided hemiplegia, contractures, sepsis, and urinary retention, was cognitively intact with a BIMS score of 14/15. On a specific date, the resident was observed to be in discomfort, complaining of burning and pain during urination, and a discharge was noted from the penile area. Nursing staff obtained orders to collect a urine sample and remove the catheter. Subsequently, the resident was diagnosed with a urinary tract infection and started on antibiotics. Despite these significant changes in the resident's condition, there was no communication with the hospice service regarding the plan of care, treatment, and interventions for the urinary tract infection. The hospice nurse assigned to the resident was unaware of the concerns related to the Foley catheter and the new clinical issues. The facility's policy required notifying hospice about significant changes in the resident's physical status and clinical complications, but this communication did not occur, resulting in a lack of collaboration between the facility and hospice services.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was readily accessible for all 79 residents and their families or visitors. This deficiency was identified through observation, interview, and record review. On December 10, 2024, the Administrator was asked to provide the daily staff postings for the past three months. Upon review, it was found that several dates in October, November, and December had no daily staff postings available for review. The Administrator explained that the scheduler was responsible for posting the daily staff information, and on weekends, this task was usually handled by the receptionist. However, multiple instances of missing documentation were noted, indicating a failure to consistently post the required staffing information.
Failure to Resolve Resident Grievance on Timely Assistance
Penalty
Summary
The facility failed to adequately follow up and resolve grievances for a resident, identified as R503, who was experiencing issues with timely assistance for bathroom needs. Despite the resident voicing concerns about delayed help, which exacerbated their constipation, the facility did not effectively address the issue. The resident had previously reported the problem, but during an observation, they recounted an incident where a CNA turned off their call light and forgot to assist them, highlighting ongoing neglect in addressing their needs. The facility's grievance process was not properly executed, as evidenced by the incomplete documentation on the Concern Form. Although the Director of Nursing (DON) claimed the issue was resolved by addressing constipation with medication, there was no follow-up on the timeliness of assistance. Additionally, the DON and RN A mentioned informal discussions with staff about call light response, but there was no formal education or documentation to support these efforts. This lack of comprehensive follow-up and documentation contributed to the deficiency in handling the resident's grievance.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency as required. The incident involved a resident who was reportedly pushed by a Certified Nursing Assistant (CNA) during a brief change. The resident, who had diagnoses including Morbid Obesity and a Pressure ulcer of the right heel, was dependent on staff assistance for most activities of daily living and had moderately impaired cognition. The incident was reported by the resident's family member, who also notified the police. The police investigated the incident but found no evidence of bruising or sufficient evidence to support the claim. Despite the family notifying the police, the facility did not report the allegation to the State Agency for review, as confirmed by the facility Administrator. The facility's policy requires that all allegations of abuse, neglect, or mistreatment be reported immediately to the Administrator and the State Survey Agency, especially if the allegation involves abuse or results in serious bodily injury. However, a review of the State of Michigan's facility reported incidents system did not show that the allegation had been reported, indicating a failure to comply with the reporting requirements.
Failure to Follow Bed Mobility Plan of Care
Penalty
Summary
The facility failed to ensure that bed mobility was completed according to the plan of care for a resident, leading to a deficiency in providing adequate supervision to prevent accidents. The resident, who was dependent on staff assistance for most activities of daily living and had moderately impaired cognition, required two-person assistance for bed mobility as per their care plan. However, a Certified Nursing Assistant (CNA) did not follow this plan and performed the task alone, which involved rolling the resident during a brief change. A complaint was submitted alleging that the resident was pushed by a facility staff member, and a police report was filed. The investigation revealed that the CNA did not use two staff members as required, resulting in the CNA holding the resident with one hand while changing them with the other. This action was contrary to the resident's care plan, which specified the need for two-person assistance to ensure safety during bed mobility.
Failure to Provide Required Abuse Training to CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received the required training on abuse policies and procedures before working with residents. This deficiency was identified during a review of a complaint involving a resident who was allegedly pushed by a facility staff member. The incident was reported by the resident's family member, who claimed that the resident was hit on the back by a midnight CNA. A police report was filed, but the officer found no evidence of bruising on the resident. The resident involved in the incident had been admitted to the facility with diagnoses including morbid obesity and a pressure ulcer on the right heel. The resident was dependent on staff assistance for most activities of daily living and had moderately impaired cognition, as indicated by a BIMS score of 12. The facility's investigation into the incident did not provide documentation that the CNA involved had received the necessary training on abuse policies and procedures prior to caring for the resident. The facility's policies require training for new and existing staff on prohibiting, preventing, and identifying abuse, neglect, and exploitation. This training should occur upon hire, annually, and as needed. However, there was no documentation that the CNA had signed off on receiving this training before the incident. The facility administrator acknowledged the lack of training documentation and mentioned plans to improve the process for ensuring agency CNAs are trained before working with residents.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document follow-up and resolve grievances for a resident, identified as R901, who was reviewed for dignity and respect. On a specific date, a concern was submitted to the State Agency alleging that R901 was not treated with dignity and respect, and their concerns were not being followed up on. During an observation, R901 reported issues with a medication not being administered in a timely manner and stated that despite emailing the Director of Nursing (DON), no follow-up was conducted regarding the resolution of this concern. A review of R901's medical record revealed that they were admitted to the facility with a diagnosis of pain and required assistance with most activities of daily living. R901 had an intact cognition as indicated by a BIMS score of 15. The facility's grievance log did not document the medication concern raised by R901 on a specific date, and several other grievances reported by R901 were found to be incomplete, lacking documentation of follow-up and resolution. The DON acknowledged receiving an email from R901 regarding the medication delay but did not document the concern on a grievance form. The email from R901 detailed a delay in receiving prescribed pain medication due to a nurse's lack of access to the system. The DON's response did not address the medication access/delay concern. The facility's grievance process policy requires prompt efforts to resolve concerns and document actions taken, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a complex urinary diagnosis. The resident, who was admitted with a history of recurrent complicated urinary tract infections (UTIs) with multidrug-resistant bacteria, a ureteric stent for hydronephrosis, and chronic kidney disease stage 3, did not have a care plan addressing these conditions. Despite the preadmission documents from the transferring hospital detailing the resident's medical history and ongoing treatment needs, the facility did not create a care plan to manage the resident's urinary tract infection, ureteric stent, hydronephrosis, or chronic kidney disease. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs. However, a review of the care plans revealed that no such plan was implemented for the resident's urinary conditions. The Director of Nursing acknowledged that a care plan should have been in place upon admission but did not provide further explanation or documentation by the end of the survey.
Failure to Provide Timely Showers for Resident
Penalty
Summary
The facility failed to ensure timely showers were provided for a resident, identified as R302, who was reviewed for Activities of Daily Living (ADL). The resident was admitted with diagnoses including sciatica, dementia, leukemia, and hearing loss, and was cognitively intact with a BIMS score of 15/15. The resident required assistance with all transfers and had a care plan that included assistance with bathing or showering as needed. However, documentation revealed that the resident did not receive a shower during their stay and only received bed baths starting over three weeks after admission. Complaints were filed with the State Agency alleging inadequate grooming and lack of time for showers by staff. The Director of Nursing (DON) stated that showers or bed baths were typically provided twice a week and should be documented if provided or refused. Despite this protocol, the paper shower sheets indicated that the resident only received bed baths on specific dates, with no documentation of shower refusals or requests for bed baths. The facility's policy emphasized escorting residents to the shower, which was not adhered to in this case.
Failure to Assess and Transfer Resident Promptly
Penalty
Summary
The facility failed to adequately assess a resident, notify the physician of a change in condition, and ensure timely transfer to a higher level of care. The resident, identified as R303, was readmitted with multiple serious diagnoses, including acute respiratory failure and sepsis. Despite the resident's complaints of difficulty breathing and the family's request for hospital transfer, the facility did not perform a complete assessment or notify the physician. On the day of the incident, RN D documented stable vital signs but failed to obtain current respirations, temperature, and pulse oximetry levels, which were crucial given the resident's symptoms. The resident's family had to call 911 to transfer the resident to the hospital, where they were admitted to the intensive care unit with sepsis. Interviews with the family and the resident's roommate confirmed the resident's distress and the family's repeated requests for hospital transfer. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not done. The Director of Nursing confirmed that a full assessment with current vitals should have been conducted and reported to the physician. Additionally, care plans for the resident's urinary diagnoses were not implemented, further indicating a lapse in the facility's adherence to care protocols.
Failure to Administer Continuous Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that a resident, identified as R303, received continuous oxygen administration as prescribed by the physician. R303 was readmitted to the facility with a diagnosis of acute respiratory failure with hypoxia and required continuous oxygen delivery via nasal cannula at 3 liters per minute. A family member of R303 reported an incident where they found the resident's oxygen concentrator turned off, and upon informing the nurse, identified as RN A, the nurse was unaware of the situation. RN A acknowledged the incident and mentioned that they believed the resident had been with the beautician that day, but no staff member had informed them that the resident was not receiving their prescribed oxygen. The Director of Nursing (DON) confirmed that there should be no exceptions to providing continuous oxygen to residents prescribed such treatment. An investigation was initiated after the incident was reported. The facility's policy on oxygen administration mandates that RNs and LPNs ensure compliance with physician orders and clinical best practices. However, no further documentation or explanation was provided by the facility by the end of the survey, indicating a lapse in adherence to the policy and a failure to ensure the resident's prescribed care was consistently administered.
Failure to Implement Baseline Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to implement an effective baseline care plan for a resident, identified as R402, who was admitted with chronic respiratory failure, a tracheostomy, and required continuous enteral feeding. Despite the resident's critical condition and need for specific care interventions, the facility did not include an intervention for proper positioning in the care plan, which is crucial for residents receiving enteral feeding and having a tracheostomy. This omission was identified during a review of the resident's care plans, which lacked any mention of positioning strategies to prevent complications associated with tube feeding. The deficiency was highlighted when a nursing note documented that upon a nurse's arrival for a shift, the resident was found unresponsive with a brown substance around the tracheotomy area, and CPR was initiated. The Director of Nursing later confirmed that the resident's code status was full code, and emergency services were called. The facility's standard practice was to implement proper positioning and physician orders upon admission, which was not done for R402, unlike another resident with similar needs who had the intervention implemented on the day of admission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pomeroy Living Rochester Skilled Rehabilitation | 2.6 mi | ★★★★★ | 13 | 0 |
| Wellbridge Of Rochester Hills | 2.8 mi | ★★★★★ | 13 | 0 |
| Bellbrook | 3 mi | ★★★★★ | 6 | 0 |
| The Springs At Rochester Hills Rehab And Nursing C | 4.1 mi | ★★★★★ | 27 | 0 |
| Optalis Health & Rehabilitation Of Bloomfield Hill | 4.3 mi | ★★★★★ | 29 | 0 |
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