Optalis Health & Rehabilitation At Kent-crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 2320 E Beltline Se, Grand Rapids, Michigan 49546
- CMS Provider Number
- 235103
- Inspections on file
- 35
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation At Kent-crossing during CMS and state inspections, most recent first.
The facility failed to prevent significant medication errors when an antipsychotic injection order for a resident with schizophrenia was mis-transcribed in the EMR, causing multiple haloperidol decanoate injections to be given within a short period instead of once every 21 days, despite an LPN questioning the order and being instructed by a supervisor to administer it as written; the resident’s family and therapy staff later observed increased tremors, confusion, and functional decline. Another resident with schizoaffective disorder had a scheduled haloperidol decanoate injection documented as refused, but the LPN did not notify the SW, DON, or provider as required, and the injection was never re-offered, coinciding with documented behavioral decompensation, increased delusions, refusals of care, and falls. On a separate occasion, an agency LPN left mid-shift without notice and failed to pass HS medications, resulting in several residents not receiving ordered doses of antipsychotics, anti-seizure medications, opioids, a beta-blocker, and a diuretic, which the facility categorized as significant medication errors due to the potential to jeopardize health and safety.
An LPN left mid‑shift without notifying anyone, locking medication cart keys in the med room and resulting in multiple residents not receiving their scheduled HS medications. Staff discovered the abandoned keys around midnight and contacted the on‑call nurse, and a replacement RN later confirmed that no HS medications had been administered for a group of rooms and that it was too late to give them. Despite facility records documenting the missed medications and the event being identified as potential neglect related to medication administration delay, facility leadership determined it did not meet criteria for reportable neglect and did not make the required reports to the State Survey Agency or nurse licensing authorities as outlined in the facility’s abuse and neglect reporting policy.
Surveyors found widespread failures in medication administration, documentation, and post‑fall monitoring. An LPN documented giving multiple medications and a daily weight to a cognitively intact resident with renal disease that were not actually provided, and later did not return with a held dose as requested. The same resident received midodrine without vital signs being taken or any BP parameters in the order. Another resident with diabetes missed a scheduled Ozempic injection when the nurse could not locate the drug and did not notify the provider or reorder it. Required neuro checks after unwitnessed falls were incompletely documented for a resident who had multiple falls with head involvement. An RN charted psychosocial observations and dialysis‑site assessments for a resident who was off‑site at dialysis for the entire shift. In a separate event, an agency LPN left mid‑shift without notice, resulting in numerous residents not receiving scheduled HS medications. Another resident with conjunctivitis had persistent eye drainage and redness after multiple missed or undocumented doses of ordered antibiotic eye drops, with no evidence that the provider was informed of the missed doses or ongoing infection.
Surveyors observed multiple environmental and sanitation deficiencies throughout the facility, including damaged walls and cabinetry, deteriorated wall junctures, and evidence of water damage and possible pest access points in soiled utility rooms and pantries. A mop sink in a soiled utility room emitted sewer gas due to an evaporated p-trap and was connected to a chemical pre-dispense unit with faucet handles left on, creating undue back pressure on the internal vacuum breaker. Spa and shower areas contained unclean equipment, such as shower chairs with matted hair or brown and yellow staining, a shower bed with black staining under the mat, and a spa tub with wet linens and toilet paper left inside. Additional findings included bubbling and chipping paint and drywall from routine roof leaks in an activity room, a leaking valve in a converted linen room, a leaking hopper in a soiled utility room, and accumulated debris and black spots on furniture and HVAC units in a lounge.
A cognitively intact resident with end stage renal disease and chronic pain repeatedly called for help with the call light on while an LPN at the nearby med cart told her to wait, loudly sighed at her calls, and referred to her as a drug addict and drug seeking within earshot. The LPN entered the room without knocking or identifying herself, interrupted the resident’s 911 call for help by telling the dispatcher the resident was fine, offered only Tylenol for reported pain without assessing it or providing non-pharmacologic interventions, and left despite the resident stating she still needed help. The resident later reported feeling ignored, overhearing staff label her a drug addict, and feeling she was treated like “ghetto trash,” contrary to the facility’s dignity policy requiring residents be treated with dignity and respect at all times.
Surveyors found that the facility failed to obtain proper consent and provide adequate notification to resident representatives for care and treatment involving two residents. One resident with schizoaffective disorder and documented inability to make medical decisions received antipsychotic and antianxiety medications based on consent recorded as obtained from the resident, even though the resident’s representative did not consent. Another resident with paranoid schizophrenia and co-guardians was sent to offsite medical and mental health appointments without the co-guardians being informed or present, and in one instance the resident attended alone. The staff member responsible for scheduling appointments described informal and undocumented methods of notifying the guardian, and could not provide evidence that the guardian had been properly informed.
A resident with paranoid schizophrenia and cognitive deficits received multiple incorrect doses of Haloperidol Decanoate after an LPN transcribed the order as a daily IM injection over several days instead of a single injection every 21 days. The error was first uncovered when an outside mental health nurse reviewed the resident’s medications and learned from an LPN that the order was wrong and multiple doses had been given. Although the LPN admitted he had questioned the order and later became aware of the medication error during this review, he did not promptly notify the provider, the resident’s guardians, or nurse managers. The family learned of the error from the outside mental health provider before the facility contacted them, and the NP was not informed until days later, resulting in a lack of timely assessment and monitoring following the significant medication error.
Surveyors found that the facility failed to maintain clean, organized, and dignified room environments for multiple residents. One resident who was bedbound and cognitively intact had a dresser repeatedly observed over several days with dust, debris, scattered ostomy and wound supplies, scissors, and food items left in disarray. Another resident with severe cognitive impairment and a feeding tube had a room with dried enteral feeding splattered on the pump, pole, floor, and chair, scattered personal belongings on the floor, persistent dirt and dust along floorboards, and a wheelchair with missing rubber on a rear wheel; a family member also reported ongoing concerns about poor hygiene, unchanged linens, and soiled items left in the room. A third resident with significant mobility limitations had a crowded room with no clear path to the bathroom, items such as a commode lid, hanger, and food wrapper left on the floor for days, a broken picture frame on the floor, and visible dirt and debris along the floorboards.
A resident with PTSD, anemia, diabetes, and cirrhosis, who was cognitively intact but had a Kinyarwanda language barrier and care-planned communication needs, reported that a CNA refused to provide a second cup of water, pushed at her when she reached for a cup, and called her profane names, leaving her scared and unable to sleep. One CNA stated she overheard the involved CNA say, “This Bitch got me messed up,” and believed it was about the resident but did not intervene or check on the resident. The RN on duty described a conflict over water in which the resident grabbed the CNA and the CNA told her not to touch her, while the accused CNA denied using profanity and cited a language barrier and lack of knowledge of interpretation tools. These events show that the resident was subjected to verbal abuse and that staff did not consistently follow care-planned interventions for communication and behavior management.
A resident with a neurocognitive disorder had a pre‑loaded credit card, managed by his guardian, whose image was sent to the business office and then forwarded to an AIT so it could be formatted and printed for billing. The AIT thereby gained access to the card information and, according to the guardian and facility records, used it to make an unauthorized phone purchase of a motorcycle battery that was billed under the facility’s name and shipped to the facility’s address, later reimbursing the guardian in cash without reporting the incident internally. The facility’s routine Advocate Rounds tool, used by concierge staff, did not include questions about the safety or security of belongings or personal funds, and staff interviews confirmed that only the business office and the AIT should have had access to the card image, establishing that the facility failed to adequately safeguard the resident’s financial information, resulting in misappropriation.
A cognitively intact resident with a language barrier and history of trauma reported, via interpreter, that a CNA used hostile language, curse words, and insults, leaving the resident very scared and unable to sleep. An RN witnessed part of the interaction involving refusal of a second cup of water and physical contact but did not promptly report it to the Abuse Coordinator. Another CNA heard the abusive language, did not check on the resident, delayed informing the RN until the next morning, and could not recall when the incident was reported to the Administrator, despite prior training on reporting abuse. These staff actions and delays resulted in a failure to follow the abuse policy and a delay in reporting alleged verbal abuse to the state agency.
Two residents receiving enteral feeding experienced failures in labeling, timing, and cleanliness of tube feeding equipment. One resident with severe cognitive impairment and malnutrition had a feeding ordered to be off by a specific time, yet the feeding continued running with pump alarms sounding, while the pump, pole, floor, and nearby chair and belongings were splattered with dried tube feeding residue that staff did not address. Multiple staff walked past the alarm without intervening, and a family member reported visible feeding drippings on the visitor chair from the prior day. Another cognitively intact resident receiving nightly tube feeding for duodenal obstruction had an enteral feeding container and IV fluids hung without any labeling of name, date, or time, despite leadership stating such labeling was required, and repeated observations showed partially full, unlabeled feedings with residual in the tubing and soiled pumps, poles, and floors covered in dried feeding residue.
A resident with paranoid schizophrenia and a cognitive communication deficit was admitted on a regimen of Haloperidol Decanoate injections every 21 days, but an LPN incorrectly transcribed the order as daily injections over several consecutive days each month. The consulting pharmacist completed monthly medication regimen reviews and noted no irregularities, despite observing that the Haldol injection was scheduled on multiple consecutive days and not reporting or questioning the order. Under this incorrect order, nurses administered multiple Haldol injections within the same week, even after one LPN expressed concern to a supervisor and was told to give the medication as written, resulting in unnecessary antipsychotic administration.
Following a change in facility ownership, multiple residents were unable to access their personal funds held by the facility due to an unsigned and uncashed check transferring funds from the previous owner. This resulted in frustration and grievances from several residents, as the facility ran out of petty cash and could not fulfill withdrawal requests, contrary to its own policy requiring timely access to resident funds.
Multiple residents with cognitive impairment and trauma histories were subjected to sexual and verbal abuse by another resident, including unwanted kissing and derogatory language. Staff witnessed and reported these incidents to the administrator, but no incident reports were filed and the events were not reported to the State Agency, contrary to facility policy. The administrator assessed the incidents as welcome contact, despite staff statements to the contrary, and failed to implement required protective measures or documentation.
Staff witnessed and reported multiple incidents where a male resident with a history of boundary issues kissed two female residents with cognitive impairments who could not consent, and made inappropriate statements to another resident. Despite staff notifying the administrator and recognizing these as potential abuse, the administrator did not report the allegations to the State Agency as required, resulting in the potential for incomplete investigations and further unreported abuse.
A significant staffing shortage led to delayed call light responses, late medication administration, and unmet ADL needs for multiple residents. Residents and families reported increased wait times, emotional distress, and a decline in care quality following a change in ownership, with agency staff unfamiliar with resident needs. Staff confirmed that the facility operated with only half the required nurses on certain days, resulting in residents not being assisted out of bed, not receiving timely wound care, and experiencing late or missed medications.
A resident with multiple chronic conditions was transferred to the hospital due to altered mental status and shortness of breath, but her emergency contact was not notified by staff. The LPN responsible for the transfer did not inform the family, assuming the resident could do so herself, despite facility policy requiring notification. The family only learned of the hospitalization from the hospital social worker.
A resident dependent on staff for bathing, grooming, and dressing did not consistently receive scheduled showers or assistance with personal hygiene, particularly during periods of low staffing. The resident remained in bed, was not dressed or groomed as scheduled, and experienced back pain and emotional distress as a result. Staff and family interviews confirmed that these lapses were due to insufficient staffing, and facility policy requiring assistance with ADLs was not consistently followed.
The facility failed to employ a qualified Activities Director for nearly a year, allowing an unqualified Activity Assistant to assume the role without the necessary certification or supervision. This resulted in the potential for unmet psychosocial needs and a lack of person-centered activities for all 126 residents. The facility's policy regarding the activities program was not provided during the survey.
The facility failed to adhere to food safety and sanitation standards, with issues such as improperly stored and labeled food, unclean equipment, and a non-functional kitchen exhaust system. Observations included opened and unsecured food items, buildup of grime and debris in storage areas, and expired food in pantries. The ice machines had significant lime and slime buildup, and the kitchen was excessively hot due to a broken HVAC unit. These deficiencies could potentially lead to foodborne illness among residents.
The facility failed to maintain proper infection control practices and lacked an effective water management plan. An LPN did not change gloves during care for a resident with a tracheostomy, and a housekeeping aide did not follow droplet precaution protocols. Additionally, the facility's water management plan was insufficient, with stagnant water lines and discolored water observed, increasing the risk of waterborne pathogens.
The facility failed to maintain resident dignity, as evidenced by staff speaking negatively about residents, delayed responses to call lights, and lack of interaction during care. Cognitively intact residents reported feeling reluctant to ask for help, while severely impaired residents were ignored or startled by staff actions. A resident's concerns about delayed restroom assistance were not adequately addressed by the administration.
The facility failed to provide individualized activities for several residents, leading to feelings of boredom and potential decline in well-being. A resident expressed loneliness due to lack of group activities and support for independent interests. Another resident, moderately cognitively impaired, lacked support in pursuing leisure activities, spending most time in bed. A severely cognitively impaired resident was observed in bed with little engagement, expressing a desire for social interaction and use of a tablet. Another resident with Huntington's disease was restless, with insufficient activities provided.
The facility failed to ensure timely weight measurements and follow-up for residents at risk for altered nutrition status, affecting four residents. A resident experienced significant weight loss without a reweight, another high-risk resident did not receive ongoing nutritional assessments, and a newly admitted resident missed weight checks. The RD admitted to being unable to manage the workload, resulting in missed assessments, which was communicated to management but not addressed.
The facility failed to maintain a sanitary and comfortable environment, with issues such as dust, dirt, and dead ants in rooms, hot and humid spa conditions, and improper storage of linens and chemicals. Maintenance issues included holes in walls, missing vinyl coving, and non-functional exhaust ventilation. Resident rooms had peeling paint and dusty personal fans, with residents reporting discomfort. Housekeeping staff acknowledged the need for more frequent cleaning.
A facility failed to ensure a resident's call light was within reach, leading to potential unmet care needs. The resident, with a diagnosis of unsteadiness of feet, was observed with the call light on the floor and out of reach. Staff interviews confirmed the resident used the call light when it was accessible. The facility's policy mandates call lights be within reach for residents who can use them, which was not followed in this case.
The facility failed to report abuse allegations to the State Agency in a timely manner for two residents. One resident, cognitively intact, reported being assaulted by an LPN during medication administration, resulting in scratches. Another resident, with severe cognitive impairment, was observed by a hospice nurse being held down during medication administration. Despite internal investigations, neither incident was reported to the State Agency, violating the facility's policy.
A facility failed to accurately complete an MDS assessment for a resident with a tracheostomy, resulting in an inaccurate reflection of the resident's status. The resident was not documented as receiving tracheostomy services in the MDS assessment, despite physician orders and observations confirming the presence of a tracheostomy tube and related care supplies. An MDS RN acknowledged the inaccuracy, highlighting the importance of accurate documentation for appropriate care.
A facility failed to complete a Level II PASARR evaluation for a resident with a psychotic disorder and dementia, resulting in potential unmet mental health needs. The Social Services Director could not locate the necessary screening, which was found incomplete in the physician's portal.
The facility failed to implement comprehensive care plans for three residents, leading to potential unmet needs. A resident with pressure ulcers was observed without a required heel protector, another with paralysis lacked a prescribed hand splint in their care plan, and a third resident with dementia had no care plan focus for their condition. These deficiencies indicate a lack of coordination and communication among the care team.
The facility failed to follow professional standards for wound care and documentation, affecting three residents. A resident with wounds on her feet and leg did not receive timely dressing changes, and documentation was missing for several days. Two other residents also had missing documentation for wound care and meal intake. Staff interviews confirmed the expectation for daily care and documentation, but no explanations were provided for the omissions.
A resident with a history of falls and metastatic cancer to the bone fell from a wheelchair. Two LPNs moved the resident back to the wheelchair without conducting a proper assessment for injuries, contrary to facility policy. No vital signs or post-fall monitoring were documented, highlighting a deficiency in care.
A facility failed to provide trauma-informed care for a resident with a history of sexual abuse, leading to a potential risk of re-traumatization. The resident, diagnosed with major depressive disorder, anxiety disorder, and dementia, did not have a care plan addressing trauma-related needs. The Social Services Director was unaware of the resident's trauma history, and the facility lacked a policy on trauma-informed care.
A resident with severe periodontal disease did not receive timely dental services due to a lack of coordination and communication among facility staff. Despite consent from the resident's guardian for dental extractions, the facility failed to arrange the necessary care, resulting in prolonged poor dental condition and potential risk for infection. Staff interviews revealed confusion about responsibility for scheduling appointments and a lack of awareness about the resident's dental needs.
The facility failed to provide written notification of the bed hold policy to two residents upon their transfer to a hospital. One resident, admitted with muscle weakness, and another with insomnia, were transferred without receiving the necessary documentation. The Nursing Home Administrator and DON confirmed the oversight, acknowledging that the facility nurses missed providing the bed hold policy forms, leading to potential unanticipated expenses or loss of room placement.
A resident with a history of strokes experienced symptoms indicative of a stroke and DVT, including lethargy, weakness, and facial asymmetry. Despite these signs, the facility delayed notifying a physician and sending the resident to the hospital. Interviews revealed that staff had concerns about the resident's condition, but these were not acted upon promptly, leading to a delay in diagnosis and treatment.
A resident with dysphagia and aphasia was at risk of choking due to staff not following prescribed feeding protocols. Despite orders for liquids to be given via teaspoon only, staff used sip cups and straws, contrary to the resident's care plan. The SLP had communicated these precautions, but observations showed non-compliance, with sip cups and straws present in the resident's room. The facility had not updated the resident's eating assistance orders, leading to a potential safety hazard.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility due to inadequate supervision. Despite wearing a functioning Wander Alert device, the front desk receptionist mistook the resident for a visitor and allowed him to leave, ignoring the alarm. The resident was found in the parking lot and safely returned to the facility by nursing staff.
A resident with dementia and a history of wandering attempted to elope from the facility, crossing a busy street before being redirected by staff. Despite the incident, staff failed to document the event in the resident's medical records or complete an incident report. The lack of documentation was due to a misunderstanding that no further action was needed if the resident remained in visual sight, resulting in incomplete and inaccurate medical records.
The facility failed to implement proper transmission-based precautions for COVID-19 positive residents. Staff, including a CNA, LPN, and Activity Director, entered rooms with Special Droplet/Contact Precautions without the required PPE, such as N-95 masks and eye protection. Signage indicating PPE requirements was either unnoticed or misunderstood, and necessary PPE was not always available.
The facility failed to assess and ensure the safe self-administration of medication for a resident who was observed with medications at his bedside. The resident, who was cognitively intact, had not been evaluated for self-administration, and there was no care plan in place to reflect this status. Interviews with staff confirmed the oversight.
A resident requested his medical records but did not receive them in a timely manner, leading to frustration. Despite following the protocol and contacting the corporate office, the resident did not receive his records due to a lack of communication and follow-up among staff members. The Social Services Director and Medical Records Coordinator were unaware of alternative options for accessing records without incurring costs.
The facility failed to implement their Abuse and Neglect policy following an incident of verbal abuse by a visitor towards a resident. The incident was reported late, and the visitor was not immediately removed, resulting in deficiencies cited by surveyors.
A facility failed to implement and document care planned interventions for a resident with pressure ulcers. The resident, who had multiple deep tissue injuries, was often found without the required heel protectors, and staff did not document his refusals to wear them. This led to the potential for further skin breakdown and worsening of the resident's condition.
A resident with multiple sclerosis experienced significant weight loss and developed multiple pressure ulcers. Despite an initial dietary evaluation and care plan, there was no documented follow-up or reassessment of the resident's nutritional needs by the Registered Dietitian, resulting in potential unmet nutritional needs.
Significant Medication Errors from Mis-transcribed Antipsychotic Orders and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including incorrect transcription and administration of antipsychotic injections and omission of ordered medications. One resident with paranoid schizophrenia and a cognitive communication deficit was admitted with an order for haloperidol decanoate 250 mg IM every 21 days. An LPN entered the order into the electronic record incorrectly as 2.5 mL IM "one time a day starting on the 16th and ending on the 21st every month," which resulted in multiple injections being scheduled and administered within a short period instead of a single injection every 21 days. The MAR showed that the resident received haloperidol decanoate injections on multiple days in February, and the facility’s own investigation confirmed that the order was transcribed incorrectly. The resident’s family member reported noticing a decline in the resident’s condition after these multiple injections, including decreased participation in therapy, increased tremors, and confusion. Therapy documentation from the last two weeks of February noted downgraded tasks due to difficulty with fine motor tasks, poor sequencing, increased confusion, and lethargy. The same resident’s outside mental health provider discovered the error when the resident presented for her usual monthly medication review and reported she had already received the injection at the facility. The mental health nurse requested medication records and later called the facility to review the orders. During that call, an LPN at the facility read the incorrect haloperidol order and acknowledged that the resident had received multiple doses within a week. The mental health nurse documented that the LPN stated he thought the order looked unusual, had asked a supervisor for clarification, and was told to administer the medication as written. The LPN later documented in a progress note that the order in the electronic record was incorrect and that he had administered two doses, but he did not clearly recall when he reported the incident internally or whether the physician was notified at the time. The facility pharmacist stated that the resident’s total monthly dose exceeded the typical effective range and described specific clinical risks associated with excessive haloperidol dosing. Another resident with schizoaffective disorder, depressive type, had a care plan intervention to administer medications as ordered and monitor for side effects and effectiveness. This resident had an order for haloperidol decanoate 2 mL IM every 28 days with instructions to inform the social worker, DON, and provider if the injection was refused. The MAR showed the injection was documented as refused by an LPN, but there was no documentation that the social worker, DON, or provider were notified, and the injection was not subsequently administered. Staff interviews indicated that this resident experienced increased behaviors, including more frequent screaming out, attempts at self-transfer, refusals of care, verbal aggression, and falls during the following weeks. Progress notes documented refusals of care, self-transfers, delusional statements, and an IDT note referenced recent falls and delusional statements, with a psychiatry follow-up note explicitly stating that the resident had not received the scheduled haloperidol injection and that this was likely contributing to her current decompensation. Additional residents experienced omitted medications when an agency LPN left mid-shift without notice and failed to complete assigned medication administration duties. The facility’s investigation summary and medication error log for that date showed that multiple residents did not receive scheduled HS medications. One resident did not receive doses of Seroquel, Keppra, and Topamax; another did not receive a dose of oxycodone; another missed doses of metoprolol and Norco; another did not receive a dose of Lasix; another did not receive risperidone; and another did not receive olanzapine. These omissions were identified as significant medication errors based on the potential to jeopardize residents’ health and safety. The facility’s medication administration policy required medications to be administered according to physician orders and standards of practice, and required documentation of refusals and physician notification as clinically indicated, but the documented events show that medications were either administered contrary to the prescribed frequency or not administered or followed up as ordered.
Failure to Report Nurse Abandonment and Missed HS Medications to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse and neglect to the State Survey Agency and other required officials after an agency LPN left mid‑shift without notice, resulting in missed medication administration for 13 residents. On the evening in question, the LPN worked approximately the first two hours of a 7 PM to 7 AM shift, then left the building without informing leadership or giving report to another nurse, locking the medication cart keys in the medication room. Certified nurse aides later noticed the keys in the medication room and, around midnight, notified the on‑call nurse. A replacement RN from the agency arrived around 3:30 AM and confirmed that none of the HS medications for a group of rooms had been administered and that, by the time of review after 4 AM, it was too late to give the medications. Facility records, including the Summary of Medication Errors and individual medication error reports, documented that 13 identified residents did not receive their scheduled HS medications due to the LPN’s failure to pass medications and subsequent departure. The facility’s Investigation Summary categorized the event as potential neglect related to medication administration delay but concluded it did not meet criteria for reportable neglect, and therefore did not report the allegation to the State Survey Agency or to the State’s nurse licensing department at the time of the incident. The Nursing Home Administrator confirmed during interview that the LPN left mid‑shift without notice, that 13 residents did not receive their HS medications, and that the facility did not notify the State Survey Agency or the nurse licensing department as required by its abuse policy. The facility’s abuse policy required all allegations involving abuse or neglect to be reported immediately (within two hours if involving abuse or serious bodily injury, and within 24 hours if not) to the State Survey Agency and other officials. Despite this policy and the documented missed medications for multiple residents, the facility determined the event was not reportable and did not make timely reports to the appropriate authorities.
Widespread Medication Errors, Inaccurate Documentation, and Missed Neuro Checks
Penalty
Summary
Surveyors identified multiple failures to provide treatment and care according to orders, resident preferences, and professional standards, resulting in missed medications, inaccurate documentation, administration of medications without appropriate parameters, and incomplete neurological assessments after unwitnessed falls. One cognitively intact resident with end stage renal disease and chronic pain was observed during a morning medication pass where an LPN documented administration of several medications and a daily weight that had not actually been given, including a lidocaine patch, Lokelma, sevelamer, and Colace. The resident declined sevelamer until after breakfast, and the LPN removed the tablets and stored them in the cart but still documented them as administered and later confirmed she never returned to give the dose or corrected the record. The same resident reported not receiving the lidocaine patch or her daily weight, and record review showed daily weights had not been documented for over a week. The same resident had an order for midodrine for hypotension, including a scheduled dose and a PRN dose, but the order lacked blood pressure parameters. During observation, the LPN administered midodrine without first assessing or documenting vital signs and later stated she believed she had taken them but could not locate documentation. The LPN acknowledged that midodrine requires a blood pressure assessment and that there were no parameters in the order, while the nurse who transcribed the order and the NP both confirmed that parameters should have been included but were missing. Another resident with type 2 diabetes and obstructive sleep apnea had a weekly Ozempic injection documented as not given because the LPN could not find the medication; there was no documentation that the provider was notified or that the medication was reordered, and pharmacy records showed no refill request had been received. For residents who experienced unwitnessed falls, required neurological assessments were not fully documented according to the facility’s protocol. One resident had an unwitnessed fall with initiation of neuro checks, but the neuro assessment form showed missing documentation for a specified shift several days later. The same resident had another unwitnessed fall with head impact reported, and the neuro assessment record showed multiple missing entries at required times over subsequent days. Staff, including LPNs and the DON, stated that neuro checks were required after unwitnessed falls and should be documented on the neurological assessment sheet, but review confirmed missing documentation that could not verify completion of all required assessments. Another cognitively intact resident who went to dialysis three times weekly had treatment documentation completed by an RN for a shift when the resident was not in the building. The RN documented that the resident had no episodes of sadness or loneliness, that the dialysis site and port were monitored and intact, and that enhanced barrier precautions were maintained throughout the shift, even though the resident had left for dialysis before the RN’s shift began and did not return until midday. In a separate incident, an agency LPN left mid‑shift without notifying leadership, locking medication cart keys in the med room and failing to administer scheduled HS medications to multiple residents. A subsequent review showed that numerous residents each missed several scheduled nighttime medications, and a replacement nurse arriving hours later confirmed that none of the HS medications for a group of rooms had been given and that it was too late to administer them. Another cognitively intact resident with conjunctivitis had ongoing eye infection signs, including green drainage and red, irritated sclera in both eyes, observed on multiple days. The resident did not have a current antibiotic order despite visible symptoms. Record review with the unit manager and infection preventionist showed that the resident had been ordered gentamycin eye drops twice in recent weeks, but doses were missed on days when the resident was at dialysis and on at least one other occasion, with refusal or missed doses not consistently documented in progress notes. There was no evidence that the physician was notified of missed antibiotic doses, no orders obtained for late administration after dialysis, and no documentation that the provider was informed that the infection persisted. The unit manager acknowledged that progress notes and follow‑up documentation were not completed as expected and that the resident continued to have conjunctivitis because the full antibiotic course was not received.
Environmental Sanitation and Maintenance Deficiencies in Multiple Facility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas used by residents, staff, and the public. Surveyor observations identified a volleyball-sized hole in the wall under a three-compartment sink, dilapidated and water-damaged cabinetry under sinks in soiled utility rooms, and deteriorating wall junctures with holes that could be used by pests. Pantries at two nurse stations had undersink cabinetry and areas under an ice machine with accumulated debris, black spots, and water damage. A 500-hall soiled utility room had a strong odor, with a mop sink that appeared dry and emitted hot air from the floor drain, indicating an evaporated p-trap and sewer gas entering the room. The mop sink was connected to a chemical pre-dispense unit with faucet handles left on, creating undue back pressure on the internal vacuum breaker. A converted shower room used as a clean linen room contained multiple water fixtures, including a leaking valve serving a commode that left a puddle on the floor, and a 600-hall soiled utility room hopper was observed leaking from the wall. Additional observations showed unclean and poorly maintained resident care and common areas. In the 500-hall spa room, large tufts of matted hair were present in the wheels of each shower chair. In the 600-hall spa tub room, soaking wet washcloths, towels, and pieces of toilet paper were left in the tub, and a shower chair had brown and yellow staining and streaking down its legs. The garden activity room’s greenhouse area had bubbling and chipping paint and drywall due to routine roof leaks that caused deterioration at the wall juncture under the roof. In the 700-hall lounge, a cushioned chair had accumulated debris and trash under the seat cushion, and there was increased trash and debris on top of a vending machine, along with black spots and accumulation in and on the wall-mounted heating and cooling unit above it. A 300-hall shower room contained a shower bed with black staining underneath the mat.
Failure to Maintain Resident Dignity and Respect During Pain and Help Requests
Penalty
Summary
The deficiency involves the facility’s failure to provide care that promoted and enhanced a resident’s dignity and sense of well-being. Resident #130, who had end stage renal disease, chronic pain syndrome, and was cognitively intact with a BIMS score of 14/15, was observed lying in bed with her call light on, crying out for help. An LPN at the medication cart outside the resident’s open door yelled to the resident that she would have to wait and then told the surveyor that the resident was a drug addict who would yell nonstop. The LPN was positioned close enough that the resident could hear this comment. As the resident continued to call out, the LPN loudly sighed each time and repeatedly told the resident she had to wait, while continuing to prepare medications. After preparing the medications, the LPN entered the resident’s room without knocking or identifying herself and asked, “What is wrong with you?” The resident was on her personal cell phone with 911, stating she was calling because nobody helped her while she yelled out, and she was noted to be tearful. The LPN yelled to the 911 operator that the resident was fine and did not need assistance, and the dispatcher ended the call. When the resident reported she was in pain, the LPN stated she had Tylenol for her, administered the medications, and left the room despite the resident stating she still needed help. The LPN did not assess the resident’s pain or offer non-pharmacological interventions and, after exiting, again referred to the resident as drug seeking and probably withdrawing, while continuing to ignore her ongoing calls for help. In a later interview, the resident reported feeling very frustrated, stated she had to yell to get help because staff ignored her, reported overhearing the LPN call her a drug addict, and said she often heard staff complain about her and felt they treated her like “ghetto trash.” The facility’s dignity policy stated residents would be treated with dignity and respect at all times.
Failure to Obtain Representative Consent for Psychotropics and Notify Guardians of Offsite Appointments
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and obtain consent from resident representatives for care and treatment, including psychotropic medications and offsite medical appointments, for two residents. One resident with schizoaffective disorder, bipolar type, had documentation indicating moderate cognitive impairment and an inability to process and understand medical information or make informed medical treatment decisions. A probate court physician report and a Determination of Inability to Participate in Complex Decision Making form, signed by two physicians, stated that this resident was not able to make or participate in medical treatment decisions. Despite this, psychotropic medication consent forms for an antipsychotic (Perphenazine) and an antianxiety medication (Alprazolam) documented that education was provided to and consent was obtained from the resident himself. The facility’s own Psychotropic Medication Use policy required that consent for each psychotropic medication be obtained from the resident or authorized representative, with education on risks versus benefits. Social Services staff confirmed that when a resident is deemed unable to make medical decisions, informed consent must be obtained from the legal guardian or authorized representative. They further confirmed that this resident could not make medical decisions, did not yet have a legal guardian when Alprazolam and Perphenazine were initially prescribed, and that the authorized resident representative did not provide consent for these medications. As a result, the resident received psychotropic medications without consent from the appropriate representative, contrary to the facility’s policy and the documented incapacity determinations. The second resident had paranoid schizophrenia and a cognitive communication deficit and had two co-guardians appointed by court order. A family member co-guardian reported that she and her sister had always made the resident’s medical treatment decisions and routinely attended all medical appointments, including those with a local mental health authority that managed the resident’s monthly Haldol injections. The co-guardian stated that the facility sent the resident to an outside medical appointment with a staff member on one occasion and to a mental health authority appointment alone on another occasion, without notifying either co-guardian. The mental health authority nurse confirmed that it was unusual for the resident to attend without the co-guardian, who had historically been present and served as a resource and advocate. The unit clerk, who was responsible for scheduling outside medical appointments, reported that when a resident has a guardian, she is supposed to ensure the guardian is aware of outside appointments and that, if the guardian cannot attend, the facility would send a staff member. She stated she scheduled one of the resident’s appointments and attempted to notify the co-guardian by preparing a written slip with appointment information. She said she waited to hand it to the co-guardian but, not wanting to interrupt a conversation, instead placed the slip on the resident’s meal tray in the room. The unit clerk gave inconsistent accounts about whether she later spoke with the co-guardian by phone and could not recall the date or details of any such conversation. She was unable to provide documentation verifying that the co-guardian had been informed of the appointment. As a result, the resident attended at least one offsite appointment without representation from her co-guardian, despite the facility’s awareness that the co-guardian expected to be notified and typically accompanied the resident.
Failure to Notify Practitioner and Family After Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a significant medication error to the resident’s practitioner and family, which resulted in a lack of assessments and monitoring. A resident with paranoid schizophrenia and a cognitive communication deficit was admitted with a care plan that included administration of medications per physician orders. An LPN entered an incorrect order for Haloperidol Decanoate, transcribing it as a daily intramuscular injection over several days each month instead of a single injection every 21 days. This transcription error led to multiple Haldol injections being administered within a short period, as documented on the MAR and confirmed by staff interviews and records. The error was first identified externally when the resident’s Local Mental Health Authority (LMHA) nurse attempted to administer the monthly Haldol injection and was told by the resident that she had already received it at the facility. The LMHA nurse requested medication records and later called the facility to review the resident’s medications. During that call, the LMHA nurse learned from an LPN that the order had been written incorrectly and that multiple doses had been given within a week. The LPN acknowledged that the order “looked weird,” stated he had asked a supervisor for clarification, and reported he was instructed to give the medication as written. The LMHA nurse documented that the resident had received multiple doses and that the LPN believed she had received at least two doses from him. Despite becoming aware of the medication discrepancy during the medication review with the LMHA nurse, the LPN did not promptly notify the facility’s provider, the resident’s guardians, or nurse managers. The LPN later documented the conversation and discrepancy in a progress note several days after the LMHA call, and he could not recall if he had contacted the physician about the error. The resident’s family member reported learning of the multiple Haldol doses from the LMHA and stated that the facility did not contact her until days later, after she had already been informed by the LMHA. The nurse practitioner reported she was not notified of the medication errors until a later date, by which time the resident was planning discharge. The nursing home administrator confirmed that the facility discovered the medication error days after the LPN had been informed by the LMHA nurse, and that the LPN had not notified the provider, guardians, or nurse managers when he first became aware of the errors.
Failure to Maintain Clean, Organized, and Dignified Resident Room Environments
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, orderly, and comfortable environment in multiple resident rooms, as well as failure to ensure safe and appropriate management of resident belongings and care-related supplies. One resident, R8, was cognitively intact but dependent on staff for transfers and unable to get out of bed independently. Over three consecutive days of observation, surveyors noted that a dresser behind this resident’s bed had dust and debris under a bottle of stoma powder lying on its side, along with a jar of chicken bouillon, various wound and ostomy supplies, and scissors with plastic wrap hanging from the blades. These items remained in the same disorganized and unclean condition across all three days, with visible dirt, dust, and debris and supplies piled on top of each other. The resident stated that staff took care of things in his room because he could not get out of bed on his own. Another resident, R108, was severely cognitively impaired, dependent on staff for all ADLs, and had a feeding tube with a resident-specific treatment plan for enteral feeding. Observations on three separate days showed that her room remained in a persistently unclean and cluttered state. Under the heat register was a purple container of deodorant that was not removed. A chair next to the enteral feeding pole held a wadded-up fleece jacket and a tube of ointment, all splattered with a dried sticky substance resembling enteral feeding, which also covered the pump, pole, pole base, floor underneath, and the chair. Dirt, dust, and debris were noted along the floorboards and dressers, and the resident’s personal belongings were partially in tote bags and partially spilled out onto the floor, as if someone had gone through them and left items scattered. The resident’s high-backed wheelchair had the rubber missing completely around the right rear wheel. These conditions were observed repeatedly without change over the three days. Family concerns further highlighted the issues in R108’s environment and hygiene. Her family member reported ongoing concerns about the resident’s personal hygiene and room condition, stating that despite staff-provided showers, the resident complained of still feeling unclean and having body odor. The family member described that linens were not consistently changed with bed baths, that she often had to change the sheets herself, and that the resident’s hair and skin showed signs of inadequate hygiene care, including dry, flaky skin and buildup of hair oil. She also reported finding used gloves on the floor, dirty wipes in drawers, spilled hair conditioner under the bed, and enteral feeding drippings on the visitor chair and floor, which she had previously observed and addressed. The unit manager later confirmed that floors were the responsibility of housekeeping, while aides and nursing staff were responsible for keeping rooms and belongings neat and tidy and for reporting equipment issues. A third resident, R12, was cognitively intact but dependent on staff for bed-to-chair transfers and had limited physical mobility related to bilateral total shoulder arthroplasties and removal of the right shoulder. Over three consecutive days, surveyors observed that his room was crowded with a bedside dresser, walker, wheelchair, bedside commode, and dresser against the wall, leaving no clear path to the bathroom and little space to move around. Under the bedside commode, there was a cookie in a wrapper, a plastic hanger, and the lid from the bedside commode, which remained in the same place on subsequent days. A broken picture frame was also observed on the floor, and along the floorboards there was an accumulation of dirt and debris that persisted across all three days. The only noted change was that the packaged cookie that had been on the floor appeared to have been moved to the bedside table, while the rest of the clutter and dirt remained unchanged.
Failure to Protect Resident From Verbal Abuse During Water Pass
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. The resident was cognitively intact, scored 15/15 on the BIMS, spoke Kinyarwanda, and required an interpreter to communicate with health care staff. Her care plan identified communication concerns, a language barrier, and a history of trauma/PTSD, with interventions including use of interpretation services, simple questions, open-ended questions, and calm communication to promote positive interactions and prevent behavior problems. Despite these identified needs and interventions, staff interactions during the incident did not reflect the care-planned approaches. According to a progress note, the resident reported to the Social Services Coordinator, using a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, leaving her very scared and unable to sleep the rest of the night. The Social Services Coordinator recalled the incident as centering around a CNA pulling something away from the resident. An RN who was present on the night of the incident stated that the CNA was passing water, the resident requested two cups, and when the CNA refused and said she would return later with another cup, the resident grabbed a cup and then grabbed the CNA by the back of the neck. The RN reported that the CNA told the resident not to touch her and that no other staff were around at that time, and also stated that the Administrator did not interview her about the incident. Another CNA reported overhearing the involved CNA say, “This Bitch got me messed up,” while wearing earbuds and talking, and believed the CNA was talking about the resident, but did not intervene or check on the resident because she felt the CNA had been a bully. The CNA accused of verbal abuse stated she refused to give the resident a second cup of water immediately, that the resident followed her speaking in Kinyarwanda, snatched a cup of water, and grabbed her shirt, and that she told the resident not to grab her but denied calling the resident any names. The resident, interviewed with a translator, stated that when she requested two cups of water, the CNA refused without explanation, pushed at her when she reached for a cup, and said, “Fuck, Fuck Bitch,” which made her feel very bad. These accounts demonstrate that the resident was subjected to hostile and profane language by staff, contrary to her right to be free from verbal abuse and to the care-planned interventions for communication and behavior related to her trauma history and language barrier.
Failure to Safeguard Resident Credit Card Information Resulting in Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to safeguard a resident’s credit card information, which led to an unauthorized purchase by a staff member. The resident involved had a diagnosis that included frontotemporal neurocognitive disorder, and his brother/guardian managed his financial transactions. The guardian provided a copy or image of the resident’s pre‑loaded credit card, which contained the resident’s Social Security funds, to the Business Office Manager (BOM O) for payment of the resident’s bills. Because the card image could not be opened, BOM O forwarded it to the Administrator in Training (AIT R) at the direction of the former Nursing Home Administrator so that AIT R could format and print it. BOM O reported that, aside from herself, AIT R was the only other employee who would have had access to the resident’s credit card information. Subsequently, the resident’s guardian noticed an unauthorized charge on the card for a motorcycle battery purchased over the phone and shipped to the facility’s address. Store staff confirmed to the guardian that the purchase had been made via a phone order from someone at the facility, using the resident’s credit card. The guardian went to the facility intending to speak with BOM O about the charge but was instead approached by AIT R, who stated he could assist and took the information about the credit card transaction, telling the guardian he would follow up. According to the guardian, about a week or two later, AIT R contacted him and arranged to meet at a gas station, where AIT R reimbursed him in cash for the amount of the unauthorized charge, stating that the money came from a special fund and that such things happened all the time. No details of this situation were reported by AIT R to anyone else at the facility. When the resident’s August payment did not process, BOM O contacted the guardian, who explained that he had locked the card after discovering the unauthorized charge and described the reimbursement by AIT R. BOM O then reported the concern to the current Nursing Home Administrator (NHA A). Review of the credit card statement and an invoice from the store showed a phone purchase of a motorcycle battery using the resident’s Mastercard, billed under the facility’s name and shipped to the facility’s address. NHA A attempted to question AIT R, who had already resigned, but he declined to provide substantive answers, repeatedly stating he did not recall or did not know. The facility’s Advocate Rounds tool, which was used to ask residents about their experiences, did not include any questions about the safety or security of belongings or personal funds, and the Concierge reported they were instructed to ask the questions exactly as written. The new Business Office Manager (BOM M), who started later, had no knowledge of the credit card issue. The evidence gathered by the facility and surveyors supported that misappropriation of the resident’s funds occurred after the facility failed to adequately safeguard the resident’s credit card information. The facility’s internal interviews and documentation further established that the resident’s credit card image was handled in a way that allowed access beyond the business office. BOM O stated that normally they did not receive images of credit cards, but in this case, due to Medicaid application requirements and the unusual card type, an image was obtained and then forwarded to AIT R for printing. This process created an opportunity for misuse of the resident’s financial information. Additionally, the Advocate Rounds process, as described by NHA A and Concierge BB, did not include any structured inquiry into residents’ perceptions of the safety and security of their belongings or personal funds, limiting the facility’s ability to detect or prevent such misappropriation through routine resident interviews. These actions and omissions collectively led to the misappropriation of the resident’s credit card for a personal purchase by a staff member.
Failure to Implement Abuse Policy and Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by not ensuring timely reporting of staff-to-resident verbal abuse to the state agency for one resident. The resident was cognitively intact with a BIMS score of 15/15, had a preferred language of Kinyarwanda, required an interpreter to communicate with health care staff, and was independent with ADLs. Her care plan identified communication concerns, a language barrier, and a history of trauma with a goal of no behavior problems, and included interventions such as interpretation services, use of simple and open-ended questions, and calm caregiver interactions. A progress note documented that the resident reported to the Social Services Coordinator, via a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, and that she became very scared and could not sleep the rest of the night. Interviews revealed that the Nursing Home Administrator served as the Abuse Coordinator and expected staff to report any type of abuse at any time. An RN reported witnessing an interaction in which the CNA refused to immediately provide a second cup of water, the resident took a cup anyway, and then grabbed the CNA by the back of the neck; the RN acknowledged she did not report the incident to the Abuse Coordinator in a timely manner and believed she should have. A CNA stated she heard the involved CNA say, “This B**** got me messed up,” did not know to whom it was directed, and walked away without checking on the resident, later telling the RN the next morning that the CNA was “fussing” at the resident. This CNA also reported that she eventually informed the Administrator but could not recall when, despite having been trained on to whom to report such incidents. These actions and inactions by staff led to a delay in reporting the alleged verbal abuse to the state agency, in violation of the facility’s abuse policy.
Failure to Label and Maintain Clean Enteral Feeding Equipment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate labeling, dating/timing, and cleanliness of enteral feeding equipment for two residents receiving tube feedings. One resident had severe cognitive impairment, a history of CVA, and calorie-deficient malnutrition, and had physician orders for enteral feeding to be turned off at 9:00 AM. During observation late in the morning, this resident’s tube feeding was still running, and the pump alarm was sounding with an error message. An LPN who did not normally work on that hall silenced the alarm without knowing when the feeding had been started or how long it was supposed to run, and did not address the visibly dirty condition of the pump, pole, base, floor, and nearby chair and belongings, all splattered with a dried, sticky substance resembling tube feeding. Further observations showed that the same resident’s pump alarm continued to sound with an error code while the pump was not running, and multiple staff, including an RN, walked past the open room without responding to the alarm. The resident appeared frustrated, waving a hand with an angry expression. The order summary still indicated the enteral feeding was to be off at 9:00 AM, yet the feeding equipment remained in use and visibly soiled. A family member later reported that the visitor chair next to the bed had been covered with feeding tube drippings the previous day, which they stated had been dripping from the bottle. On a subsequent day, the resident’s enteral feeding and a bag of clear fluids were again observed hung on a pole and attached to the pump, with the pump, pole, base, floor, and a chair with a fleece jacket and ointment tube all splattered with a dried, sticky substance resembling enteral feeding. The second resident, who was cognitively intact and received nightly enteral feeding for duodenal obstruction and chronic vascular intestinal disorders, was observed with an enteral feeding container and a bag of clear fluids hung on a pole and connected through a pump. Neither the feeding nor the fluids were labeled with the resident’s name or with the date and time they were hung, despite the DON’s statement that tube feedings and fluids should be labeled with name, date, and time so staff would not reuse them and would know when they were hung. Later observation showed the feeding and fluids still partially full, with residual feeding in the tubing, and the pump, pole, base, and floor splattered with a dried, sticky substance resembling enteral feeding. On another day, the same resident’s pump, pole, base, and floor were again observed splattered with a sticky substance resembling enteral feeding. A unit manager confirmed that tube feeding and fluid should be dated and labeled to know when they were hung and if they were fresh, and that enteral feeding equipment should be kept clean for infection control.
Failure to Identify Incorrect Antipsychotic Order During Monthly Drug Regimen Review
Penalty
Summary
The deficiency involves the facility’s failure to identify and correct an inaccurately transcribed antipsychotic medication order during the monthly medication regimen review for one resident. The resident had diagnoses including paranoid schizophrenia and a cognitive communication deficit and was admitted with an existing regimen of Haloperidol Decanoate injections every 21 days. On admission, an LPN entered the Haldol order into the electronic medical record incorrectly as an intramuscular injection to be given daily from the 16th through the 21st of each month, with additional directions stating every 21 days. This transcription error resulted in the order appearing as multiple consecutive daily doses instead of a single dose every 21 days. The consulting pharmacist completed medication regimen reviews on two occasions and documented that there were no new irregularities in the resident’s medication regimen. During interview, the pharmacist acknowledged noticing that the Haldol injection was scheduled for multiple days in a row but assumed this was to allow nurses flexibility if the medication did not arrive on time, and therefore did not report or question the order. As a result, the incorrect order remained in place and was not identified as an irregularity during the monthly drug regimen review, despite the conflicting directions and the unusual frequency for a long-acting antipsychotic injection. According to the medication administration record, the resident received multiple doses of Haloperidol Decanoate under the incorrect order, with injections documented on several days within the same week. One LPN reported administering two doses and stated that he had questioned the order and asked his unit manager for clarification but was instructed to administer the medication as written. The resident’s family member later reported being informed by the local mental health authority that the resident had received three doses of her monthly Haldol injection in error at the facility. The mental health authority nurse documented a telephone conversation with the LPN in which he confirmed that the resident had received multiple doses within a week based on the written order. The facility’s failure to detect and correct the erroneous order during the pharmacist’s monthly medication regimen review led to the unnecessary administration of an antipsychotic medication.
Residents Denied Access to Personal Funds Following Ownership Change
Penalty
Summary
The facility failed to ensure that residents' personal funds held by the facility were accessible to them, affecting 40 residents. After a change in facility ownership, residents were unable to access their personal funds, as confirmed by interviews with residents, the Administrator in Training, and the Business Office Manager (BOM). The BOM reported that since the week following the ownership change, the facility ran out of petty cash and was unable to fulfill resident fund requests. A check containing the combined personal funds of 40 residents, totaling $21,594.90, had not been signed or cashed, preventing the transfer of funds from the previous to the new ownership. As a result, residents could not access their money for personal purchases or needs. Multiple residents expressed frustration and filed grievances due to their inability to access their funds. One resident was visibly upset and reported not having access to his money since the new company took over. Grievance forms from two other residents indicated dissatisfaction and distress over the lack of access to their funds. Facility policy requires that resident fund withdrawals be distributed within a reasonable timeframe, but this was not followed due to the unresolved transfer of funds and lack of available petty cash.
Failure to Protect Residents from Sexual and Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual and verbal abuse by another resident, resulting in several incidents of resident-to-resident abuse. Specifically, a male resident with a history of schizoaffective disorder, cognitive communication deficits, and boundary issues was observed kissing two female residents who were unable to consent due to severe and moderate cognitive impairment. Staff members, including an LPN, CNA, and PA, directly witnessed these incidents and reported them to the facility administrator. Despite these reports, no incident or accident reports were completed for the involved residents, and the administrator determined that the incidents did not require reporting to the State Agency, citing his own assessment that the contact was welcome, which was not supported by staff witness statements. The affected residents included individuals with significant cognitive impairments and trauma histories, making them particularly vulnerable. One resident had a BIMS score indicating severe cognitive impairment and a care plan noting risks related to mood and behavioral disturbances. Another resident had a moderate cognitive impairment, a history of trauma, and a care plan specifying a preference for female-only caregivers. Both were unable to recall or report the incidents, and social work notes indicated the need for ongoing monitoring due to their vulnerability. Additionally, another cognitively intact resident reported feeling uncomfortable and altering her dining habits due to the perpetrator's behavior, while another resident reported being verbally abused and emotionally distressed by the same individual. The facility's abuse prevention policy required immediate reporting, investigation, and protection of residents from abuse, including resident-to-resident incidents. However, the facility did not follow these procedures, as evidenced by the lack of documentation, failure to report to the State Agency, and insufficient protective interventions. Staff interviews revealed concerns about the administrator's handling of the situation, including the removal of a social work note describing the incident as sexual assault and the lack of appropriate response to repeated abusive behaviors. The failure to act in accordance with policy and regulatory requirements resulted in unaddressed abuse and the potential for emotional distress among vulnerable residents.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual and verbal abuse to the State Agency in a timely manner for five residents. Multiple staff members, including an LPN, CNA, and Social Worker, witnessed or were informed of incidents where a male resident, who was cognitively intact but had a history of boundary issues, kissed two female residents with cognitive impairments who could not legally consent. These incidents were reported internally to the facility's administrator, who was made aware of the potential abuse but chose not to report the allegations to the State Agency, contrary to facility policy and regulatory requirements. The administrator assessed the residents himself and determined that the contact was welcome, despite staff statements and documentation indicating otherwise. The residents involved included individuals with significant cognitive impairments and histories of trauma, making them particularly vulnerable. One female resident had a BIMS score indicating severe cognitive impairment, while another had moderate impairment and a history of trauma. Both were unable to consent to the contact. Staff notes and interviews revealed that the incidents were not welcomed by the residents, and in at least one case, a resident was visibly in shock and did not respond to the incident. Another resident, who was cognitively intact, reported feeling uncomfortable and changed her dining habits to avoid the male resident after a separate incident involving inappropriate verbal and physical behavior. Despite multiple staff members recognizing these incidents as potential abuse and expressing concern that failure to report could lead to further incidents, the administrator did not initiate the required reports to the State Agency. Facility policy required immediate reporting of any abuse allegations, including those involving residents who could not consent, but no incident or accident reports were found for the affected residents. The lack of timely reporting resulted in the potential for incomplete investigations and further unreported abuse.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by multiple reports of delayed responses to call lights, late medication administration, and unmet activities of daily living (ADL) needs. Several residents reported waiting 30 minutes to over an hour for staff to respond to call lights, resulting in discomfort, emotional distress, and, in some cases, incontinence episodes. Residents and their families noted a decline in staffing levels and care quality following a recent change in facility ownership, with an increased reliance on agency staff unfamiliar with residents' needs. Documentation and interviews revealed that on specific days, the facility operated with only half the required number of licensed nurses and was also short on certified nursing assistants (CNAs). This staffing shortage led to residents not being assisted out of bed, not being dressed, not receiving timely wound care, and not having their bed linens changed. Medication administration records showed that medications were given several hours late, and some residents did not receive necessary blood sugar checks or insulin as scheduled. Staff interviews confirmed that the facility was aware of impending staffing shortages but was unable to secure adequate coverage, and that the situation caused significant frustration among both staff and residents. Residents with complex medical needs, such as those with pressure ulcers, diabetes, and cognitive impairments, were particularly affected. Family members reported concerns about late medications and unmet care needs, leading to at least one resident being discharged to another facility. Staff, including LPNs and the nursing staff coordinator, described the situation as "horrible" and "hellish," with some staff responsible for an unmanageable number of residents and medication carts. The facility's own policies and facility assessment indicated that staffing should be based on resident acuity and care plans, but these standards were not met during the period in question.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in condition that resulted in hospitalization. Specifically, a female resident with a history of kidney disease, diabetes, and high blood pressure experienced altered mental status and shortness of breath, leading to her transfer to the hospital. Documentation showed that the resident's emergency contact was not notified of the transfer, and the transfer form indicated that notification had not occurred. The family member only learned of the resident's hospitalization and unresponsive state from the hospital social worker, not from the facility. Interviews revealed that the LPN responsible for the transfer did not contact the resident's emergency contact, believing the resident was alert and able to notify her family herself. However, facility policy required that the resident's representative be notified of significant changes in condition and transfers, regardless of the resident's alertness. The interim DON confirmed that family notification should occur in all such cases. The failure to notify the family resulted in them being unaware of the resident's decline and subsequent hospitalization.
Failure to Provide Consistent ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident who was dependent on staff for bathing, grooming, and dressing due to impaired mobility from multiple fractures and moderate cognitive impairment. The resident was scheduled to receive showers twice weekly, but records showed that she was not offered a shower for 3 out of 7 scheduled opportunities within a specified period, and did not receive any unscheduled showers. Interviews with family, staff, and the resident confirmed that she often remained in bed, was not dressed or groomed, and missed scheduled showers, particularly during periods of low staffing, especially on weekends. The resident expressed frustration and embarrassment about her appearance when not assisted with bathing and grooming, and reported back pain from remaining in bed too long. Family members and staff corroborated that the resident's personal hygiene and grooming needs were not consistently met, and that these lapses were linked to staffing shortages. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and dignity, but this was not consistently implemented for the resident in question.
Facility Lacks Qualified Activities Director
Penalty
Summary
The facility failed to employ a qualified Activity Director, which resulted in the potential for unmet psychosocial needs and a lack of person-centered activities for all 126 residents. The facility had been without a qualified Activities Director for nearly a year, during which time an Activity Assistant was allowed to assume the role without the necessary qualifications. This individual, identified as AD NN, did not possess the required certification and was not supervised by a qualified individual. The facility's job description for the Activities Director position required eligibility for certification as a therapeutic recreation specialist or activities professional, or completion of a state-approved training course. However, AD NN had not been in the director role long enough to take the certification test. The facility's policy regarding the overall activities program and the role of the director was requested but not provided during the survey. Interviews with staff, including the Nursing Home Administrator, confirmed the lack of a qualified Activities Director and the absence of proper supervision for the individual in the role.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a kitchen/food service tour. In the freezer, opened cases of hamburger patties, Salisbury steaks, and egg patties were not securely closed, posing a risk of contamination. The freezer floor had a buildup of dirt, grime, and debris, and a broken plastic cover from a sprinkler head was found on the floor. In the reach-in cooler, a rack with trays of prepared food had a buildup of dried food product and debris. In the storeroom, opened boxes of chocolate cake mix and flaked coconut were not securely closed, and the floor was soiled with debris and dust. In the 600-hall nourishment room, there was significant lime buildup on the ice machine, and the refrigerator had dried spillage. A condiment tray contained spilled sugar packets, and a CNA's lunchbox was improperly stored in the refrigerator. In the 300-hall nourishment room, a lunchbox was not labeled or dated, and opened beverages lacked discard dates. The beef broth was not discarded after 7 days, and there was dried spillage in the freezer. The kitchen was hot and humid due to a non-functional exhaust system, and the floor mixer had dried debris. A black hose connected to the dish machine lacked an atmospheric vacuum breaker, and the 500-hall pantry had expired food and slime debris in the ice machine. The 100-hall pantry contained commercially prepared salsa and hummus with incorrect discard dates, and condiments were at risk of contamination. The 600-hall pantry's ice machine had slime debris, and the facility's maintenance director confirmed that a vendor services the ice machines quarterly. The report cites several sections of the 2022 FDA Food Code, highlighting the facility's failure to maintain cleanliness, proper food storage, and equipment maintenance, which could lead to foodborne illness among residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain safe infection control practices, as observed in the care of two residents. For one resident with a tracheostomy and gastrostomy, an LPN did not change gloves after touching potentially contaminated surfaces and before performing tracheostomy care. This oversight occurred despite the resident being highly susceptible to infections due to their medical conditions. The LPN admitted to not changing gloves during the procedure, which could lead to cross-contamination and the spread of bacteria. In another instance, a housekeeping aide did not adhere to droplet precaution protocols while entering a resident's room. The aide failed to wear eye protection and did not change gloves or wash hands after exiting the room. The facility's policy required staff to don eye protection, gloves, gown, and mask before entering rooms with droplet precautions, but these measures were not consistently followed. Additionally, the facility lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. Observations revealed stagnant water lines, discolored water, and infrequent flushing of unused fixtures. The maintenance director was unaware of some stagnant water lines and admitted that the facility's water management plan was not fully implemented, increasing the risk of waterborne pathogens spreading within the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of several residents, as evidenced by multiple observations and interviews. Resident #26, who was cognitively intact, reported overhearing staff speaking negatively about residents, which made her feel reluctant to ask for help. This was corroborated by a Registered Nurse who confirmed that staff often spoke disrespectfully about residents. Additionally, during a confidential meeting, several residents reported long wait times for call light responses and overheard staff socializing instead of attending to their needs, leading to feelings of frustration and decreased self-worth. Resident #55, who was severely cognitively impaired, was observed being moved by a CNA without any verbal interaction, causing the resident to appear startled. Similarly, Resident #57, also severely cognitively impaired, was assisted with eating by a CNA who engaged in a loud personal conversation with another CNA, ignoring the resident. These actions likely contributed to a decreased sense of self-worth and frustration for the residents involved. Resident #112, who was cognitively intact, reported an incident where a CNA delayed assistance for restroom use, citing other duties, and later ignored the resident's call light while using a cell phone. The resident's concerns were reported to a social worker, who confirmed overhearing disrespectful interactions and reported them to the administration. However, the Nursing Home Administrator was unaware of these issues, indicating a lack of communication and follow-up within the facility. Disciplinary records for the CNA involved showed previous warnings for disrespectful behavior, highlighting ongoing issues with staff conduct.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities for several residents, leading to feelings of boredom and a potential decline in their well-being. Resident #26, who was cognitively intact, expressed feelings of boredom and loneliness due to the lack of group activities and support for independent leisure interests. Despite the resident's preferences for reading materials, religious activities, and being around pets, the facility did not facilitate these activities, especially during periods when group activities were suspended due to infection control measures. Resident #39, who was moderately cognitively impaired, also experienced a lack of support in pursuing leisure activities. The resident's family member reported that the facility did not assist with the resident's interest in music and social activities. Observations showed that the resident spent most of the time in bed with little engagement in activities, despite having a care plan that included interests in music, socializing, and religious activities. The facility's activity participation records indicated extended periods without any activity involvement for the resident. Resident #42, who was severely cognitively impaired, was observed spending all his time in bed, with little engagement in activities. The resident expressed a desire for social interaction and the use of a computer tablet, which was no longer available to him. The facility had tablets available for residents, but the activity assistant was unaware of the resident's needs. Similarly, Resident #55, who had Huntington's disease and was severely cognitively impaired, was observed to be restless and spent most of the time sitting in a geri chair near the nurse's station. The facility did not provide enough activities for the resident, and there was a lack of communication with the resident's family to understand his interests and preferences.
Failure in Nutritional Monitoring and Assessment
Penalty
Summary
The facility failed to ensure timely and consistent weight measurements and follow-up for residents at risk for altered nutrition status, affecting four residents. Resident #59 experienced a significant weight loss of 13.7% in one month, but a reweight was not obtained despite multiple requests from the Registered Dietitian (RD). The RD reported that reweights should be obtained within a day or two to implement new nutritional interventions if needed, but the Certified Nurse Aides (CNAs) responsible for obtaining reweights did not fulfill this requirement. Resident #111, who was at high risk for nutritional status alteration due to tube feeding and a stage IV pressure ulcer, did not receive ongoing nutritional assessments. The RD acknowledged that only one dietary evaluation was completed since admission, and no subsequent nutrition/weight progress notes were documented. The RD admitted to being unable to keep up with the workload, which resulted in missed assessments for high-risk residents like Resident #111. Resident #121, a newly admitted resident with a gastrostomy, missed several weight checks despite being at risk for malnutrition. The RD reported that new admissions should be weighed weekly, but this was not done. Similarly, Resident #89, diagnosed with unspecified protein-calorie malnutrition, had not received a dietary evaluation since June 2024, despite significant weight loss. The RD admitted to being behind on assessments due to an unmanageable workload, which was communicated to facility management but not addressed. The Director of Nursing was unaware of the missed assessments and the RD's workload issues.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a tour, several deficiencies were observed, including an accumulation of dust, dirt, sand, and dead ants in various rooms. The 600 hall spa room was found to be hot and humid, with moisture dripping down the windowsills and black debris on the window frame. Open and exposed linens were laid out on a shower bed, and urine remover and personal hygiene products were stored together on the same shelf. Additionally, holes in the concrete wall of the 600 linen closet allowed air to enter the room, and the 100 hall clean utility room had a gap between the floor and wall due to missing vinyl coving. In the 500 hall spa, a cloth-backed chair was found near the shower area, and a used brief was half hanging out of the trash receptacle. The alarm cord was stained, and there was dried brown debris on the wall near the commode. The 400 hall spa room had a roll of toilet paper on the ground, and a plastic cart with gloves and briefs was stored next to the sink and commode. The facility's maintenance director acknowledged that some exhaust ventilation was down, contributing to a foul odor in the 600 hall soiled utility room. The janitor's closet in the 200 hall had a chemical pre-dispense with water left on under constant back pressure, which was not approved for the fixture. Several resident rooms had issues with peeling and chipped paint, and personal fans were found to be caked with dust and debris. Residents reported that the dust from the fans blew into their eyes, and despite requests for cleaning, the fans remained uncleaned. Housekeeping staff confirmed that resident fans should be dusted multiple times a week, but the housekeeping account manager admitted that audits were only conducted once a month. These observations indicate a lack of regular maintenance and cleaning, leading to an unsanitary and uncomfortable environment for residents.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance and potential unmet care needs. Resident #27, who was admitted with a diagnosis of unsteadiness of feet and had a care plan indicating a need for a safe environment with the call light in reach, was observed with the call light on the floor and out of reach. The resident reported using the call light when staff remembered to place it within reach. Interviews with a registered nurse and a certified nursing assistant confirmed that the resident used the call light when needing assistance. The facility's policy requires call lights to be within reach of residents who can use them, but this was not adhered to in this instance.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for two residents, resulting in the potential for additional allegations of abuse to go unreported and delayed investigation. Resident #115, a cognitively intact female with adjustment disorder, reported being assaulted by a nurse during medication administration, resulting in scratches to her chest. Despite the resident's grievance and the involvement of multiple staff members in the investigation, the allegation was not reported to the State Agency. Resident #127, a male with severe cognitive impairment and multiple diagnoses, was involved in an incident where a hospice nurse observed him being held down by staff during medication administration. The hospice nurse reported care concerns to the facility, leading to the suspension of the involved LPN pending investigation. However, the allegation was not reported to the State Agency, despite the facility's awareness of the hospice nurse's concerns and the subsequent internal investigation. The facility's policy requires all allegations of abuse to be reported immediately to the appropriate State Agencies, but this was not adhered to in the cases of Resident #115 and Resident #127. The failure to report these allegations in a timely manner resulted in a deficiency citation, highlighting the potential for further unreported incidents and delayed investigations.
Inaccurate MDS Assessment for Resident with Tracheostomy
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, resulting in an inaccurate reflection of the resident's status. The resident, who was admitted with a tracheostomy, was not documented as receiving tracheostomy services in the MDS assessment dated 12/18/24. This discrepancy was identified through a review of the resident's physician orders, which included instructions for regular tracheostomy care, and an observation that confirmed the presence of a tracheostomy tube and related supplies in the resident's room. An interview with the MDS Registered Nurse revealed that the resident had a tracheostomy upon admission, and the MDS record was acknowledged as inaccurate. The Long-Term Care Facility Resident Assessment Instrument Manual specifies the importance of accurately coding special treatments, such as tracheostomy care, to ensure the appropriateness of care provided. The failure to accurately document the resident's tracheostomy care in the MDS assessment could lead to an inaccurate understanding of the resident's needs and care requirements.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident, resulting in the potential for unmet mental health and psychiatric care needs. The resident was admitted with a diagnosis of psychotic disorder with delusions and had a Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening that indicated the presence of mental illness and dementia. The screening also noted that the resident had received treatment for mental illness, was on antipsychotic or antidepressant medications, and exhibited significant disturbances in thought, conduct, emotions, or judgment. Despite these indicators, the Social Services Director (SSD) responsible for coordinating the facility's PASARR screenings was unable to locate the resident's Level II screening. Upon further investigation, it was discovered that the Level II screening had not been completed in a timely manner, as it was found in the facility's physician's online portal awaiting completion. This oversight highlights a lapse in the facility's process for ensuring necessary evaluations are conducted to address the mental health needs of its residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential unmet medical, physical, mental, and psychosocial needs. Resident #73, who had a history of stroke, dementia, pressure ulcers, and reduced mobility, was observed without a padded boot on her right foot despite having a pressure wound on her right heel. The care plan for Resident #73 included the use of heel protectors, but observations revealed non-compliance with this intervention, as her right heel was resting directly on the mattress. Resident #97, with a diagnosis of right-side paralysis following a stroke, was observed without a splint device on his right hand, which was prescribed to prevent contractures. The care plan for Resident #97 did not include orders for the hand splint, and the Therapy Director confirmed that the resident was prescribed a splint in May 2023. However, there was no record of the splint in the resident's care plan or therapy notes, indicating a lack of coordination and communication among the care team. Resident #27, diagnosed with dementia, did not have a care plan focus related to this diagnosis. The Social Services Director and Registered Nurse Unit Manager confirmed that all residents with dementia should have a care plan addressing their condition, but Resident #27's care plan lacked this essential component. This oversight highlights a failure in the facility's process for developing and implementing comprehensive care plans tailored to each resident's needs.
Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice for wound care and documentation, affecting three residents. Resident #230, who was cognitively intact, had wounds on her bilateral feet and left lower leg. Despite physician orders for daily dressing changes, observations revealed that her dressings had not been changed for two days, with visible wound drainage present. The Treatment Administration Record (TAR) showed missed documentation for wound care on specific dates, and there was no progress note explaining the missed treatments. Resident #27 also experienced lapses in wound care documentation. The TAR indicated missing entries for wound care on multiple dates for different wound sites, including the left buttock, right toes, and an old suprapubic catheter site. Interviews with staff confirmed the expectation for daily wound care and documentation, yet there was no explanation for the missed entries in the resident's records. Resident #89's meal intake documentation was incomplete on several dates, despite the facility's policy requiring documentation of all services provided to residents. Interviews with a CNA and the DON confirmed the expectation for documenting meal intake to monitor nutritional status. The DON reviewed the electronic health records and confirmed the missing documentation for both wound care and meal intake, with no further documentation explaining the omissions.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to properly assess a resident after a fall, which was identified during a review of Resident #48's care. Resident #48, who was admitted with a diagnosis of unsteadiness on feet and had a history of falls, experienced a fall from his wheelchair. Despite the resident's medical history of metastatic cancer to the bone, which increased his risk of fractures, the Licensed Practical Nurses (LPNs) involved did not conduct a thorough assessment before moving him. The LPNs lifted the resident back into his wheelchair without checking for potential injuries, such as deformities or pain, and did not document any vital signs or initiate post-fall monitoring. Interviews with the Unit Manager and LPNs confirmed that the facility's policy, which requires a full assessment before moving a resident post-fall, was not followed. The Unit Manager acknowledged that a proper assessment, including range of motion and vital signs, could not be completed in less than a minute, and that the resident's condition warranted careful evaluation due to his increased risk of fractures. The lack of documented vital signs and post-fall monitoring further highlighted the deficiency in care provided to Resident #48 after his fall.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who was a trauma survivor, resulting in a potential for re-traumatization. The resident, who had a history of sexual abuse at age 10, was admitted with diagnoses including major depressive disorder, anxiety disorder, and dementia. Despite this history, the facility did not have a care plan in place to address the resident's trauma-related needs. The Social Services Director (SSD) was unaware of the resident's trauma history, as it was not assessed during the initial social work assessments for residents admitted more than a few years ago. The deficiency was identified during an interview with the SSD, who confirmed that the resident had not been assessed for any trauma-related triggers. The SSD acknowledged the importance of knowing a resident's trauma history to prevent re-traumatization during care. Additionally, the Nursing Home Administrator reported that the facility lacked a policy related to trauma-informed care, further contributing to the oversight in addressing the resident's psychosocial needs.
Failure to Facilitate Timely Dental Services for Resident
Penalty
Summary
The facility failed to facilitate timely dental services for a resident with severe periodontal disease, resulting in prolonged poor dental condition and potential risk for life-threatening infection. The resident, who was severely cognitively impaired due to Huntington's disease, had a history of dental infections requiring antibiotics and hospitalization. Despite consent from the resident's guardian for dental extractions, the facility did not successfully arrange for the necessary dental services. The resident's medical records indicated multiple attempts by the Nurse Practitioner to coordinate dental care, including referrals for extractions and the need for sedation due to the resident's inability to cooperate during dental exams. However, there was a lack of communication and coordination among facility staff, leading to confusion about who was responsible for scheduling the dental appointments. The Medical Records Coordinator and Unit Secretary were unaware of the referral, and the Director of Nursing was not informed that consent had been obtained. Interviews with facility staff revealed a breakdown in communication and responsibility, with staff members unsure of the status of the resident's dental care and referrals. The Director of Nursing and other staff members were unaware of the resident's need for dental extractions and the consent that had been obtained. This lack of coordination and follow-through resulted in the resident not receiving the necessary dental care, despite the known risks and previous recommendations for extractions.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents upon their transfer to an acute care hospital. This deficiency was identified for two residents who were reviewed for emergency hospital transfers. Resident #102, who was admitted with a diagnosis of muscle weakness, was transferred to a hospital on 10/18/24. Although the transfer note indicated that a medication list and facesheet were sent with the resident, there was no documentation to confirm that the bed hold policy was provided. Similarly, Resident #103, admitted with insomnia, was sent to a local hospital following a medical specialty appointment, but there was no documentation indicating that the bed hold policy was provided upon discharge. During the survey, the Nursing Home Administrator and the Director of Nursing confirmed that the facility could not provide the bed hold policy forms for these residents. The Director of Nursing acknowledged that the facility nurses were expected to provide the bed hold policy form to residents when they were transferred to the hospital, but this was missed in the cases of Resident #102 and Resident #103. This oversight resulted in the potential for unanticipated expenses or the loss of desired room placement for the residents.
Failure to Address Acute Change in Condition
Penalty
Summary
The facility failed to address an acute change in condition for a resident, resulting in a delay in treatment for a subacute cerebral vascular accident (CVA) and an acute right lower extremity deep vein thrombosis (DVT). The resident, who had a history of strokes, exhibited symptoms such as increased lethargy, right upper extremity weakness, facial asymmetry, decreased grip strength, and increased pain, warmth, and swelling in the right knee. Despite these symptoms, the facility did not notify the physician promptly or send the resident to the hospital for evaluation. The resident was initially assessed after a fall, and subsequent evaluations noted a decline in mentation and increased pain in the right hip and knee. However, the facility's medical staff, including a nurse practitioner and physician assistant, did not recognize the neurological changes as indicative of a stroke. The resident's guardian was not informed of the neurological symptoms, which contributed to the delay in seeking emergency medical care. Interviews with facility staff revealed that there were concerns about the resident's condition, but these were not acted upon in a timely manner. The medical director was not informed of the potential stroke symptoms, and the nurse practitioner believed the resident's condition was at baseline. It was only after persistent concerns from nursing staff and the resident's guardian that the resident was eventually sent to the hospital, where a stroke and DVT were diagnosed.
Failure to Follow Prescribed Feeding Protocols for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure the safety of a resident with specific dietary needs, leading to a potential risk of choking. The resident, who had a history of aphasia and dysphagia following a stroke, was prescribed a pureed diet with thin liquids to be administered via teaspoon only, with no straws or sip cups allowed. Despite these clear orders, observations and interviews revealed that the resident was provided with liquids using sip cups and straws, contrary to the prescribed method. This was observed on multiple occasions, and staff members, including CNAs, were found to be using sip cups and straws, believing it was easier for the resident, despite the risk of choking due to the resident's impaired cognition and need for frequent swallowing cues. The Speech Language Pathologist (SLP) had communicated the specific feeding precautions to the staff, and these were documented in the resident's orders and Kardex. However, there was a disconnect between the prescribed care and the actual care provided, as evidenced by the presence of sip cups and straws in the resident's room. Interviews with staff, including the Kitchen Manager and LPN, confirmed that the orders were not being followed, and there was a lack of adherence to the feeding assistance orders. The Director of Nursing acknowledged that the facility had not updated the resident's eating assistance orders, despite the SLP's recommendations, indicating a lapse in communication and implementation of care protocols.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, who had severe cognitive impairment and a history of wandering and exit-seeking behavior, was able to exit the facility without staff knowledge. The resident was wearing a Wander Alert electronic monitoring device, which was functioning properly and sounded an alarm when the resident approached the exit. Despite the alarm sounding, the front desk receptionist did not respond appropriately. The receptionist mistook the resident for a visitor and allowed him to exit the building without verifying his status or ensuring he had permission to leave. The receptionist admitted to turning off the alarm, which she claimed made noise frequently, and did not check if the resident was authorized to leave. This inaction allowed the resident to reach the parking lot before being noticed by another resident, who alerted the nursing staff. The nursing staff responded promptly once informed by another resident, redirecting the eloped resident back into the facility. The incident highlighted a lapse in the facility's protocol for responding to door alarms and ensuring residents at risk of elopement are adequately supervised. The resident was found unharmed and was placed under 1:1 supervision following the incident.
Failure to Document Elopement Incident for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident #107, who was at risk for wandering and elopement. The resident, diagnosed with dementia and other conditions, had a history of wandering behaviors and wore a WANDER ALERT bracelet as a preventive measure. On the day of the incident, the resident attempted to elope from the facility, successfully leaving the premises and crossing a four-lane street before being redirected back by staff. Despite the seriousness of the event, there was no documentation of the incident in the resident's medical records, nor were there any incident reports filed. Interviews with staff revealed that the resident had removed his WANDER ALERT bracelet prior to the elopement attempt, and staff members were aware of the incident as it unfolded. However, the staff did not document the event in the resident's progress notes or complete any standard assessments on the day of the incident. The lack of documentation was attributed to a misunderstanding among staff that no further action was needed if the resident remained in visual sight. This oversight resulted in an incomplete and inaccurate medical record for the resident, failing to provide an accurate picture of the resident's status and condition. The Director of Nursing (DON) acknowledged being informed of the incident shortly after it occurred but admitted to not ensuring that the necessary documentation and incident report were completed. The failure to document the resident's behavior escalation, the removal of the WANDER ALERT bracelet, and the attempted elopement highlights a significant deficiency in maintaining accurate medical records, which is crucial for effective resident care and safety.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to implement proper transmission-based precautions and ensure the use of required Personal Protective Equipment (PPE) when entering rooms of COVID-19 positive residents. Observations revealed that staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), entered rooms with Special Droplet/Contact Precautions without donning the necessary PPE, such as N-95 masks, gloves, and eye protection. The signage on the doors clearly indicated the need for these precautions, yet staff either did not notice the signs or did not have access to the required PPE. In one instance, a CNA entered a room with an open door, responding to a call light while wearing only a surgical mask, despite the posted requirement for an N-95 mask and other PPE. The CNA was unaware of the additional precautions due to the open door and lack of visible signage. Similarly, an LPN entered the same room with only a surgical mask and gown, citing the absence of N-95 masks in the PPE bin as a reason for not following the protocol. Further observations showed that an Activity Director also entered a COVID-19 positive resident's room wearing only a surgical mask, misunderstanding the PPE requirements as applicable only during direct care or potential contact with body fluids. The Director of Nursing/Infection Preventionist confirmed that both COVID-19 positive and negative residents in shared rooms should be under the same Special Droplet/Contact Precautions, requiring full PPE for all staff entering these rooms.
Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure the safe self-administration of medication for Resident #105. Resident #105, who was cognitively intact with a BIMS score of 15, was observed with a medication cup containing two tablets on his bedside table. The resident reported that the tablets were Vitamin B12 and Folic Acid, which he intended to take with his lunch. However, a review of the physician's orders revealed that the medications were Folic Acid and Thiamine HCl (Vitamin B1), not Vitamin B12. The resident had not been assessed for the ability to self-administer medications, and there was no care plan in place to reflect self-administration status. Interviews with the Director of Nursing (DON) and the Registered Nurse Unit Manager (RNUM) confirmed that an assessment should have been completed to ensure the resident's safety in self-administering medications. Both the DON and RNUM acknowledged that the resident had not been evaluated for self-administration and should not have had medications at his bedside. A review of the resident's care plan also showed no documentation regarding self-administration of medications.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to respond timely to a request for medical records from a resident, resulting in delayed access and frustration. Resident #105, who was cognitively intact with a BIMS score of 15, requested his medical records on 2/12/24. Despite following the protocol explained by a nurse aide, he did not receive any response. After contacting the corporate office, several staff members spoke to him, but he still did not receive his records. The Social Services Director (SSD) was unaware of the request, and the Medical Records Coordinator (MRC) assumed the resident no longer needed the records after an initial conversation. The Nursing Home Administrator (NHA) was also unaware of the request until informed by the corporate office. The MRC explained to Resident #105 that there was a cost involved in obtaining copies of his medical records and that his entire record would be extensive. The SSD and MRC were uncertain about alternative options for the resident to access his records without incurring costs. The NHA stated that if she had known about the request earlier, she would have made alternate arrangements for the resident to access his records. The lack of communication and follow-up resulted in the resident not receiving his requested medical records in a timely manner.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility failed to implement their Abuse and Neglect policy following an incident of verbal abuse by a visitor towards a resident. The incident involved a male resident with significant medical conditions, including major depressive disorder and cognitive communication deficit. The altercation occurred in the dining room when the resident did not move quickly enough for the visitor, leading to a verbal confrontation. The activity director witnessed the incident but did not report it immediately, resulting in a delay in notifying the state agency and removing the visitor from the facility pending an investigation. The Nursing Home Administrator (NHA) acknowledged that the incident was reported late because the activity director did not bring it up until the next day's morning meeting. The visitor was not asked to leave the facility immediately after the incident and continued to interact with other residents. Interviews with staff confirmed that the visitor used disrespectful and abusive language towards the resident, who was visibly upset by the encounter. The delay in reporting and the failure to remove the visitor promptly were cited as deficiencies. The facility's policy on abuse and neglect mandates immediate reporting of all alleged violations, but this protocol was not followed. The activity director admitted to not reporting the incident right away due to a lack of understanding, which led to a teachable moment from the NHA. The state operations manual requires that all alleged violations involving abuse be reported within two hours, a standard that was not met in this case.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement care planned interventions or document refusals of care planned interventions to prevent further skin breakdown for a resident with pressure ulcers. The resident, who was cognitively intact and had pertinent diagnoses including end-stage renal disease and type 2 diabetes mellitus, had multiple deep tissue injuries (DTIs) on his left foot and heel. The care plan required the resident to wear heel protectors while in bed to prevent further skin breakdown. However, during multiple observations, the resident was found lying in bed without the heel protectors, and his heels were directly on the mattress. The resident reported not knowing when the heel protectors were supposed to be on, and staff interviews revealed that the resident often refused to wear the heel protectors, but these refusals were not documented in the medical record as required by the care plan. Interviews with the Licensed Practical Nurse Unit Manager (LPNUM) and Certified Nurse Aides (CNAs) confirmed that the resident frequently refused to wear the heel protectors, and there was no documentation of these refusals in the nursing notes or by the CNAs. The LPNUM also did not indicate any alternative methods discussed to prevent skin breakdown if the resident refused to wear the heel protectors. Additionally, a Registered Nurse (RN) reported that the order to document refusals of the heel protectors was only put in on the day of the interview, indicating a lack of prior awareness of the need for this intervention. The failure to implement and document the care planned interventions resulted in the potential for further skin breakdown and worsening of the resident's condition.
Failure to Document Nutritional Follow-Up After Significant Weight Loss and Skin Breakdown
Penalty
Summary
The facility failed to ensure timely and consistent documented follow-up by a qualified nutrition professional following significant weight loss and skin breakdown in a resident. The resident, who had multiple sclerosis and other pertinent diagnoses, was admitted with a risk score indicating a risk of malnutrition. Despite an initial dietary evaluation and care plan, the resident experienced significant weight loss and developed multiple stages of skin breakdown over a period of time. However, there was no documented follow-up or reassessment of the resident's nutritional needs by the Registered Dietitian (RD) after the initial assessment. The resident's weight was monitored weekly, showing a significant weight loss from 191 pounds to 175.5 pounds within a month. Additionally, the resident developed multiple pressure ulcers, including an unstageable ulcer on the left hip and stage 1 to stage 3 ulcers on the sacrum and ankles. Despite these significant changes in the resident's condition, there was no documented evidence of follow-up or reassessment by the RD after the initial dietary evaluation. The RD reported that follow-up was attempted but could not provide evidence of it. The RD acknowledged that the resident's nutritional status should have been reassessed and documented, especially after the significant weight loss and development of skin breakdown. The RD mentioned that a nutrition supplement was added for extra calories and protein, but this was not documented in the medical record. The lack of documented follow-up and reassessment resulted in the potential for unmet nutritional needs for the resident.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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