Optalis Health & Rehabilitation Of Bloomfield Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield Hills, Michigan.
- Location
- 2975 N Adams Road, Bloomfield Hills, Michigan 48304
- CMS Provider Number
- 235217
- Inspections on file
- 38
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Bloomfield Hill during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain an effective infection prevention and control program, including missing gloves in PPE carts for rooms on contact precautions and delayed posting of Enhanced Barrier Precaution signage for a readmitted resident. Several symptomatic residents with documented cough, congestion, fever, leukocytosis, shortness of breath, nausea, vomiting, lethargy, and difficulty with arousal were not tested for COVID-19 despite facility policy and CDC guidance. Staff did not consistently follow contact precautions, hand hygiene, or safe medication handling, including entering a contact precaution room without PPE, touching pills with bare hands, and failing to perform hand hygiene between tasks. Wound care was performed while the nurse flicked unrestrained hair and moved in and out of a contact precaution room without appropriate PPE or hand hygiene. PPE bins contained a heavily soiled mask stored with clean masks and dried brown residue on the exterior, and multiple staff opened and closed these bins without addressing the contamination until later intervention, while the DON acknowledged that these practices were inconsistent with facility expectations.
The facility failed to ensure adequate nursing coverage on an upper-level unit, resulting in multiple residents not receiving their scheduled 9:00 PM medications on time. A complaint alleged there was no nurse on the unit for several evening hours and that help did not arrive until late in the shift. Staffing records and time punches did not align with the posted nurse assignments, with one LPN leaving before the end of the assigned period, a salaried LPN unit manager lacking any time punch, and an RN unit manager clocking in more than two hours after medications were due. Despite this, the RN unit manager documented administration of numerous 9:00 PM medications, including anticoagulants, antihypertensives, insulin, anticonvulsants, and pain medications, after her recorded start time, and the facility could not produce corroborating evidence of her actual work hours or detailed medication administration timing.
The facility failed to maintain an effective antibiotic stewardship program for two residents by not documenting required infection criteria or the appropriateness of prescribed antibiotics. For one resident with psychiatric diagnoses, cephalexin was ordered for a reported UTI and earlier infection signs, but the McGeer criteria form was blank, the record lacked documentation of the stated symptoms, and there was no evidence of review of hospital labs or culture reports. For another resident with serious mental illness, Augmentin was ordered multiple times for UTI, the infection report and McGeer worksheet lacked documented signs and symptoms, and progress notes described behavioral issues without infection complaints, while the MAR showed interrupted and then completed antibiotic courses. The ICP reported verbally reviewing antibiotics with physicians but acknowledged that these reviews were not documented, and no records of such reviews for these residents were produced.
A bedbound resident with contractures, functional quadriplegia, muscle wasting, unclear speech, severely impaired cognition, and total dependence for ADLs was repeatedly observed with only a standard push-button call light clipped to the blanket, despite being unable to hold or press it. A family member could not confirm the resident’s ability to use the device, and the resident indicated she could not activate it. A unit manager RN initially believed the resident could use the standard call light but, upon direct observation, confirmed she could not and acknowledged the need for a different type of call light. The DON stated residents unable to use a standard call light should be assessed for an appropriate alternative, and facility policy required review of each resident’s unique needs and preferences for call light use, which was not done for this resident.
Surveyors identified that the facility did not maintain a sanitary and homelike environment for three residents. One resident was observed in a room with garbage scattered on the floor and a wall splattered with a brown substance, with no change noted on re-observation later the same day. In another room shared by two residents, the floor on both sides was littered with trash and debris and appeared unmopped, one overbed table was dirty and discolored, a nightstand had dried tube feeding formula on the top and front, and the other overbed table was dirty and sticky. A family member, when asked about room cleaning, pointed to the trash and shrugged, and a later observation with the Maintenance Director confirmed the room remained in the same unclean condition despite a facility policy requiring housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Surveyors found that staff failed to accurately assess, document, and respond to changes in condition for three residents, and failed to ensure and document hospice services for another. One resident with dementia and total ADL dependence had shortness of breath and declining SpO2 reported by the spouse; staff obtained conflicting BP readings including 215/160, did not confirm manually, and documented only a normal manual BP and partial vitals, while EMS later found hypoxia, tachycardia, hypotension, and fever consistent with sepsis. A second resident with cardiac disease and diabetes had nausea, vomiting, poor intake, and abnormal labs faxed to the physician with no evidence of review or new orders, and no additional BP documentation on the day EMS found prolonged hypotension and dehydration. A third resident with prior respiratory failure and hemiplegia had documented SOB, tachycardia, abnormal vitals, and NP/MD orders for labs, IV fluid boluses, and metoprolol adjustments, but labs were not resulted, the IV bolus was not documented as given, metoprolol was administered at a higher total dose than ordered, and undocumented breathing treatments were reportedly given without orders as SpO2 fell below 85% before EMS found the resident unresponsive with severe hypoxia. Separately, a hospice resident with severe cognitive impairment had an active hospice order and care plan, but hospice documentation in the facility lacked names and dates of visiting staff, and no hospice CNA sign-in sheets were found for several weeks despite hospice reporting weekly nurse and CNA visits.
Two residents with pressure injuries did not receive consistent, ordered wound care and preventive interventions. One resident with multiple comorbidities had physician orders for specific heel and ankle wound treatments on scheduled night shifts, but surveyors found dressings dated several days earlier and the TAR showed a missed treatment, with an LPN unable to identify who was responsible or why it was not done. Another resident with documented stage 3 coccyx, sacral, and right buttock pressure injuries had hospital instructions and a care plan calling for a low air-loss or specialty mattress and q2h turning with wedges, yet was observed in bed without a low air-loss mattress or wedges; the resident reported painful wounds, and staff later acknowledged the absence of the ordered mattress and that hospital discharge notes indicating stage 3 wounds and the need for a low air-loss mattress had not been reviewed.
A resident with dementia, osteoporosis, impaired cognition, incontinence, and significant ADL assistance needs experienced two unwitnessed falls from bed. The care plan and IDT documentation identified fall risk and specified interventions including a mattress overlay/bolsters and a non-skid mat at the bedside. During observations, the resident was found on a regular mattress without bolsters or overlay on the bed and no non-skid mat on the floor, while the overlay was seen in the wheelchair. The assigned LPN was unaware of the overlay intervention, the unit manager initially asserted it was in place before acknowledging it was not, and the DON stated interventions would not be documented until implemented, despite existing documentation indicating they were already ordered.
A resident with quadriplegia and dependence for all ADLs was repeatedly documented as weighing about 149 lbs by Hoyer lift, despite appearing very thin on observation. A December weight of 121.6 lbs was crossed out by an LPN as incorrect, and subsequent entries again showed weights near 149 lbs. When surveyors observed staff reweigh the resident with a mechanical lift, the actual weight was 120 lbs, nearly 30 lbs less than the most recently charted value. The RD stated the weights had appeared stable and therefore had not raised concern, and the DON reported that CNAs obtained and entered weights but did not explain the discrepancy. No facility policy on weight management or obtaining accurate weights was provided when requested.
Surveyors observed that two residents received incorrect laxative formulations during routine medication passes, leading to a medication error rate above 5%. One resident was given Senna Plus (senna/docusate) when the order was for senna alone, and another was given Geri-Kot (senna only) when the order was for a senna/docusate combination. In both cases, LPNs prepared and administered medications that did not match the physician orders, and the DON later confirmed that these substitutions were not appropriate under the facility’s medication administration policy.
A resident with multiple medical conditions developed new and worsening wounds, including a stage IV sacral ulcer, while dependent on staff for all care. The facility did not document notifying the resident's family about these changes, despite the family's involvement in care discussions and the expectation that such notifications should occur.
A resident with multiple medical conditions and a stage IV sacral pressure ulcer developed purulent drainage that was not reported to the physician, despite care plan requirements. No documentation of physician notification or wound treatment was found before the resident was transferred to the hospital, where the wound was found to be infected with multiple organisms.
A resident who was fully dependent on staff and had a chronic Foley catheter did not have consistent documentation of catheter care over several months. The resident was later hospitalized with a urinary tract infection, and facility staff were unable to provide records showing that catheter care was performed as ordered.
A resident dependent on staff for all ADLs and with a PEG tube experienced a clogged tube and significant drainage, with soiled towels left in place and no clear explanation from staff. There was no consistent documentation of PEG care, and no current physician orders were found. Nursing staff failed to document care or incidents related to the PEG tube, resulting in a lack of appropriate and timely care.
Surveyors found unsanitary and unkempt conditions in multiple common areas, including dining rooms, a community room, and a shower room. Observations included dried food spills, debris, personal items stored inappropriately, insect webs, soiled linens, and unlocked cabinets containing PPE and syringes. Facility leadership acknowledged the concerns during the inspection.
A resident's authorized representative, acting for a person with severe dementia, was not provided timely access to requested medical records, including care plans and therapy notes, despite repeated requests and facility policy requiring access within 24 hours. The records were not supplied for over two months, and the delay was documented in both grievance forms and staff interviews.
Two residents did not receive care according to physician orders: one was not scheduled for a dermatology consult despite ongoing skin concerns and repeated requests, while another went multiple days without prescribed medications after hospital readmission due to delays in pharmacy supply and lack of backup medication processes.
A resident with severe cognitive impairment and psychiatric diagnoses had changes made to their Seroquel regimen without informed consent from their representative, and did not receive timely psychiatric evaluations or medication reviews. The facility did not coordinate psychiatric services effectively, as the contracted psychiatrist was not permitted by the family and the psychiatric NP was unable to see the resident due to scheduling conflicts. Social services did not fulfill their responsibility to obtain consent or arrange alternative psychiatric care, resulting in a lack of medically related social services.
A resident with multiple medical conditions was not referred to an oral surgeon for surgical extraction of two decayed molars as ordered by a dentist. Although the dentist provided instructions and an antibiotic prescription, facility staff did not arrange the necessary referral or document any actions taken, contrary to facility policy.
A resident reported repeated delays in receiving scheduled medications, including seizure medications, with audit records confirming multiple instances of late administration outside the facility's one-hour window policy. The DON was made aware of these concerns after the resident expressed frustration and anxiety over the late medication times.
A resident's antipsychotic medication dosage was increased without timely notification to the responsible party. Documentation showed that neither the psychiatric provider nor social services informed the family of the change, and the issue was only addressed after a grievance was filed. Facility policy requires such notifications, but records did not reflect compliance in this case.
A resident's responsible party was not notified or included in care conferences, and the facility failed to provide documentation of care conferences as required by its own policy. This resulted in a deficiency related to the coordination and documentation of care planning.
A resident with significant mobility limitations and multiple diagnoses was found using a non-medical grade heating pad applied by a CNA, with no physician order, care plan, or documentation. Facility staff and leadership were unaware of the device's use, and facility policy did not allow such equipment, resulting in a lack of supervision and accident prevention.
A resident with significant mobility and medical needs did not receive timely incontinence care, resulting in prolonged exposure to soiled bedding and strong urine odor. Staff interviews and documentation revealed that the resident was not changed for over 30 hours, with no evidence of care refusal during that period. Facility policy requiring regular perineal care and proper documentation was not followed, and communication between shifts was lacking, leading to poor hygiene and potential risk for impaired skin integrity and UTI.
A resident in a LTC facility was subjected to a urine toxicity test without their consent, violating their rights. The resident, who was cognitively intact, reported feeling discriminated against and stated that the facility did not explain the reason for the test. Interviews with staff revealed a lack of awareness and documentation regarding the test's purpose and the facility's consent protocol. The facility administrator confirmed the absence of a specific policy on toxicology consent, despite residents' rights to refuse treatment.
A resident with dementia and wandering behaviors was involuntarily secluded by staff in a dining room, restricting their movement. The incident was observed by other residents and staff, who reported that tables were used to trap the resident. The facility's investigation confirmed the inappropriate actions, leading to disciplinary measures against the involved staff.
A resident with dementia was involuntarily secluded by a CNA and an LPN, as reported by another resident. The incident was not reported to the Administrator or State Agency in a timely manner, violating the facility's policy. Two CNAs observed the incident but failed to report it, leading to a delayed investigation.
A resident with chronic anemia and other health issues did not receive a prescribed erythropoietin stimulating agent for several months due to insurance non-coverage, leading to multiple hospitalizations. Despite the resident and family raising concerns, the facility failed to administer the medication or seek alternatives, resulting in avoidable hospitalizations and blood transfusions.
The facility failed to maintain sanitary conditions in the kitchen and pantry refrigerators, with observations of pooled milk, soiled shelving, and expired food items. Additionally, kitchen staff with beards were not wearing beard restraints while handling food, violating FDA Food Code requirements.
The facility did not employ a full-time licensed social worker as required for its size, affecting the psychosocial care of 122 residents. The lapse occurred after a previous social worker's license expired, and attempts to cover the gap with part-time staff were insufficient. The issue was attributed to oversight by HR in tracking license expirations.
The facility failed to employ a qualified full-time social worker and provide necessary medically related social services, affecting all 120 residents. The Administrator was unaware of the issue until informed, and the part-time social worker's license had expired. There was also a lack of coordination for mood and behavior management, psychotropic medication oversight, care plan development, and guardianship follow-through.
The facility failed to maintain a clean and homelike environment, with observations of soiled floors, walls, and pest harborage. Complaints were made about housekeeping not keeping the facility clean. Residents' rooms and common areas were found in poor condition, with unsanitary conditions in dining areas. The administrator acknowledged the issues, but no audits were maintained to monitor them.
The facility failed to provide adequate social services for residents, including mood and behavior management and guardianship coordination. A resident's behaviors due to unaddressed pain were not documented, and care plans for psychotropic medication use were lacking. Another resident with severe cognitive impairment had no legal guardian, and social services did not follow up on guardianship recommendations for two residents.
A resident with severe cognitive impairment was prescribed multiple psychotropic medications without adequate documentation or monitoring of targeted behaviors. The facility failed to implement timely care plans and did not attempt a gradual dose reduction. Interviews revealed a lack of specific details about the resident's symptoms, leading to prolonged unnecessary medication use.
A resident with severe cognitive impairment was not treated with dignity and respect as staff failed to address another resident's inappropriate behavior of telling them to "Shut-up." Despite attempts to redirect the resident, staff were observed laughing and did not intervene appropriately, violating the facility's policy on treating residents with kindness and respect.
A resident with significant cognitive impairment and medical conditions was not provided with an appropriate wheelchair or Geri-chair, despite expressing a desire to get out of bed. Observations showed the resident remained in bed due to the lack of suitable seating, and staff were unaware of this deficiency. Interviews revealed a lack of communication and awareness among staff regarding the resident's needs, and the facility's policy on accommodation of needs was not provided during the survey.
A resident with multiple health issues reported not receiving a prescribed medication for several months, despite raising the concern with facility administration and their physician. The resident's family also communicated the issue through meetings and emails, but the facility failed to document or resolve the grievance. The administrator acknowledged the concerns but did not follow the grievance process, leaving the issue unresolved.
A facility failed to complete an annual OBRA Level II Evaluation for a resident with vascular dementia and bipolar disorder, despite a mental status exam indicating intact cognition. The necessary 3878 dementia exemption form was not completed, and the Social Services Coordinator was unaware of available resources to address the issue.
A facility failed to create resident-specific care plans for a resident with behavior-emotional needs and psychotropic medication use. The resident, with a history of dementia and mood disorders, was observed yelling loudly, yet care plans lacked specific details on mood and behavior management. The facility's policy did not ensure resident-specific care plans, and the interdisciplinary team was noted as responsible for this oversight.
A resident in a non-smoking facility was found to have smoking materials unsecured in their room, despite staff being aware of their smoking habits. The resident, with a history of nicotine dependence, smoked without supervision, contrary to the facility's non-smoking policy. Observations and interviews revealed that staff, including a CNA, knew of the resident's smoking, yet no measures were taken to secure the materials or provide adequate supervision.
A facility failed to maintain a medication error rate below five percent, resulting in an 8.33% error rate. An LPN administered enteric-coated aspirin instead of the prescribed chewable aspirin to three residents, with two receiving crushed enteric-coated aspirin. The DON acknowledged the error, noting that enteric-coated medications should not be crushed and must be administered as per physician orders.
The facility did not provide residents and visitors access to previous survey results, leaving them uninformed of identified deficiencies. The policy on Resident Rights allows residents to examine survey results and correction plans, but the survey information binder lacked documentation from recent surveys. The Administrator acknowledged the binder was not updated and attributed the responsibility to a newly hired Assistant Administrator, without explaining who was responsible before.
A resident, who was his own responsible party, was prevented from leaving the facility to visit his storage unit due to staff incorrectly claiming he needed a guardian's permission. Despite having intact cognition and no legal guardian, staff threatened to commit him to a psychiatric unit if he attempted to leave, causing distress. The facility's actions were based on incorrect assumptions about the resident's legal status, leading to a violation of his rights.
A facility failed to conduct a thorough skin assessment and clarify hospital discharge instructions for a resident with a wound, leading to inconsistent wound care. The resident reported severe pain and dissatisfaction with the care. Hospital instructions for wound treatment were not accurately reflected in facility orders, resulting in missed treatments and conflicting care recommendations from the facility's wound care provider and the orthopedic surgeon.
A resident with long, painful toenails and a foot condition did not receive physician-ordered podiatry care due to a lack of consent documentation and unclear financial explanations. Despite multiple orders for podiatry services, the resident was not seen by a podiatrist since admission, leading to ongoing pain and difficulty walking. The facility lacked documentation of the resident's refusal and a policy on podiatry care.
The facility failed to provide necessary social services for two residents, leading to deficiencies in guardianship, discharge planning, and coordination of ancillary services. One resident, a veteran, was not provided with guardianship verification or timely competency evaluation, and his podiatry care needs were unmet. Another resident on hospice status lacked a legal guardian and advance directives, and the facility did not allow the legal guardian to sign a do-not-resuscitate order. The social services director and staff did not fulfill their responsibilities, resulting in significant oversights in care and support.
The facility failed to maintain a clean and safe environment on the second floor, affecting several residents. Observations revealed strong odors, rusted equipment, and unsanitary conditions in residents' rooms, including sticky floors and scattered debris. Housekeeping staff acknowledged issues with thorough cleaning, and a safety hazard was identified in the 2 East Lounge/Dining Room with an exposed receptacle box. Interviews with staff and residents highlighted the facility's failure to adhere to its cleaning policy.
The facility failed to report a resident-to-resident abuse incident to the State Agency within the required time frame. A resident with a history of aggression assaulted another resident, and the night shift staff did not intervene. The incident was reported to the police by the day shift RN, but the State Agency was notified six and a half hours later. Communication lapses and delays in reporting were noted among the staff.
A resident with dementia and a history of wandering and aggression entered another resident's room multiple times, resulting in physical assault. Despite staff presence, the resident was able to repeatedly intrude and attack, highlighting a failure in supervision and safety protocols.
The facility failed to protect three residents from physical and verbal abuse by staff and other residents. One incident involved a CNA slapping a resident, which was confirmed by video footage and led to the CNA's termination and legal charges. Another incident involved resident-to-resident physical abuse, with staff confirming the altercation. The facility's policy emphasized the importance of an abuse-free environment, but deficiencies were noted in protecting residents.
Failure to Maintain Effective Infection Prevention, Surveillance, and PPE Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an ongoing infection prevention and control surveillance system and to consistently implement its own infection control policies and procedures. Surveyors observed multiple lapses in the use and availability of personal protective equipment (PPE) for residents on Contact Precautions and Enhanced Barrier Precautions (EBP). For one resident on contact precautions, signage required staff to don gown and gloves before entering, but the PPE cart outside the room contained no gloves; another PPE cart across the hall was also missing gloves, which was confirmed by the unit manager. A resident readmitted from the hospital over a weekend was placed on EBP only after the surveyor had already entered the room, and the unit manager could not explain why the required signage had not been posted earlier, later stating that nurses were responsible for ensuring orders were entered correctly upon readmission. The infection surveillance program did not ensure that symptomatic residents were tested for COVID-19 in accordance with facility policy and CDC guidance. Infection report forms and clinical notes documented that several residents had symptoms consistent with respiratory infection and possible COVID-19, including cough, congestion, wheezing, productive cough, stuffy nose, headache, fever of 101.5°F, leukocytosis, shortness of breath, nausea, vomiting, loose stools, lethargy, and difficulty with arousal. Despite these documented symptoms for multiple residents, their medical records contained no documentation that they had been tested for COVID-19 as required by the facility’s COVID-19 policy and CDC testing guidance. When interviewed, the Infection Control Preventionist stated that symptomatic residents should be tested and that the facility followed CDC guidance and its own policy, but was unable to explain why these particular symptomatic residents were not tested. Additional infection control failures were observed in the implementation of contact precautions, hand hygiene, medication handling, and environmental cleanliness. A resident on contact precautions for CRE in the urine had a sign on the door, but the isolation cart outside the room had no gloves. Another resident on contact precautions reported that staff were not wearing gowns and gloves when entering the room, and there was no garbage can in the room or bathroom for disposal of PPE. During medication administration, one LPN moved between units, used a computer, retrieved backup medications, and administered them without performing hand hygiene. Another LPN picked up a pill that had fallen onto a resident’s lap with a bare hand and returned it to the medication cup, and also poured a pill from a stock bottle into the palm of an ungloved hand before administration. During wound care, the wound treatment nurse flicked unrestrained long hair away from the face and continued wound treatment with the same gloves, and for a resident on contact precautions, entered the room and placed wound care supplies on a dresser without PPE, then later removed gown and gloves to obtain more supplies without performing hand hygiene. Surveyors also identified failures related to EBP signage and PPE bin sanitation. One resident’s door initially had no indication of any precautions, and CNAs entered with a mechanical lift and provided care without PPE; upon exiting, an EBP sign had been placed on the door requiring gown, gloves, and mask for all staff providing care. An agency CNA stated it was their first day back and that the sign had not been on the door before entering. On the same unit, a PPE bin contained a heavily soiled mask with dried brown and orange stains stored among clean masks, and another bin had a dried brown substance on the outside that had to be touched to open the drawers. Multiple CNAs opened the contaminated bin drawers and closed them without removing the soiled mask or discarding the clean masks stored with it, until an LPN removed the soiled mask and threw it away. Central supply staff later stated that all clean masks in the bin had to be disposed of and the bins sanitized, noting that one bin had an odor. When interviewed, the DON acknowledged that nurses should not touch pills with bare hands, that hand hygiene should be performed using soap and water when visibly soiled or alcohol-based hand rub otherwise, and that gloves should be kept in the isolation cart, while also stating understanding of the concerns raised by these observations.
Insufficient Nursing Staff Leading to Delayed Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff on the 2 [NAME] Unit, resulting in residents not receiving medications according to physician orders. A complaint alleged that on the evening of 12/25/25, the unit was short staffed from 7:00 PM to 11:00 PM, with no nurse present during that time and residents not receiving medications timely. The complainant reported that staff said help would be sent, but no one arrived until 11:20 PM. During interviews, the Staffing Coordinator stated that two night nurses had called in and that nurse managers came in to cover, including a salaried unit manager who was not required to punch in. The Administrator and Staffing Coordinator later identified nurses assigned to the unit based on an assignment sheet, but time punch records did not fully support those assignments. Review of the 12/25/25 assignment sheet for the 2 [NAME] and 2 East Units showed that a unit manager LPN and another LPN were assigned from 7:00 PM to 11:00 PM, and a unit manager RN and another RN were assigned from 11:00 PM to 7:00 AM, with the RN also listed as assigned to 2 East during the same time. Time punch records revealed that the LPN listed for 7:00 PM to 11:00 PM had actually punched out at 8:59 PM, and the salaried LPN unit manager had no time punch. The RN unit manager assigned from 11:00 PM to 7:00 AM did not punch in until 11:15 PM, and the other RN assigned to that shift punched out at 11:45 PM. No missed punch documentation was provided to reconcile these discrepancies, and the facility could not produce evidence of the exact hours worked by the nurse managers. Record review of residents on the 2 [NAME] Unit showed that three residents had multiple medications scheduled for administration at 9:00 PM on 12/25/25, including atorvastatin, Colace, Eliquis, metoprolol tartrate, tizanidine, divalproex sodium, Voltaren gel, Lantus insulin, and gabapentin. All of these 9:00 PM medications for the three residents were documented as administered by the RN unit manager who did not punch in until 11:15 PM, more than two hours after the scheduled administration time. During interview, the DON stated he had not been aware of staffing challenges that day, while the ADON reported that nurse managers came in. The RN unit manager later reported she had come in early but did not punch in until 11:15 PM and had not requested a missed punch because she was a manager, and she could not provide evidence of her arrival and departure times. The facility reported that corporate staff were unable to access an audit report of medication administration times, and no further documentation was provided before the end of the survey.
Failure to Maintain Effective Antibiotic Stewardship and Document Appropriateness of Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective antibiotic stewardship program and to monitor the appropriateness of antibiotic use for two residents. For one resident with a history of anxiety disorder, bipolar disorder, and adjustment disorder, an Infection Report Form dated with an onset of 12/16 documented mental status change, lethargy, and fever, and initiation of cephalexin 500 mg three times daily for 10 days. However, the attached McGeer Criteria Worksheet was left blank, and the medical record contained no documentation supporting the reported mental status change, lethargy, or fever. Nursing notes instead described the resident calling 911 due to perceived mold on the floors and difficulty breathing, with normal vital signs and lung sounds, and multiple entries reflecting disruptive behaviors, yelling, refusals of care, irritability, agitation, and frustration that appeared to be baseline. After the resident was transferred to the hospital and returned, new orders were received for cephalexin 500 mg three times daily for 10 days for a mild UTI, but there was no documentation in the record of any review of the appropriateness of the antibiotic or of hospital labs or culture reports. For the second resident, with diagnoses including paranoid schizophrenia, psychotic disorder with hallucinations, and adjustment disorder, an Infection Report Form with onset 12/11 listed Augmentin 500-125 mg every 12 hours but left the signs and symptoms section blank, and the attached McGeer Criteria Worksheet was also blank. A UA and culture showed E. coli >100,000 in the urine, but a NP note on the same date documented the resident as somewhat irate and wanting to go home, with no complaints, no respiratory distress, no discomfort, and no pain, and referenced recent verbal and physical aggression and a history of behavioral issues. The December MAR showed multiple Augmentin orders for UTI with start and stop dates resulting in incomplete courses before a full 7‑day regimen was completed, yet the record contained no documentation that the resident met infection criteria or that the appropriateness of the antibiotic therapy was reviewed. During interview, the ICP stated they run a daily report of residents on antibiotics and contact the physician to review antibiotics but acknowledged they had just realized such reviews should be documented, and no documentation of antibiotic appropriateness review for these two residents was provided by the end of the survey.
Failure to Provide Usable Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate, usable call light for a bedbound resident with significant physical and cognitive impairments. A complaint to the State Agency alleged that this resident, who was unable to use her hands, did not have a proper call light and that it was difficult for staff to know when she needed assistance. On two separate observations, the resident was seen lying in bed with her head leaned to the left and a standard push-button call light clipped to her blanket. During one observation, a family member present could not confirm whether the resident was able to use the call light. During another observation, the resident indicated by slightly shaking her head that she could not press the call light button. In an interview, the unit manager RN initially stated the resident could use a standard push-button call light, but upon direct observation with the resident, the RN attempted to place the call light in the resident’s hand and was unable to do so, acknowledging the resident could not hold it and would need a different type of call light. The DON reported that if staff noticed a resident was unable to use a standard call light, the resident should be assessed for an appropriate call light. Record review showed the resident was admitted with contractures, functional quadriplegia, and muscle wasting and atrophy, and an MDS assessment documented unclear speech, severely impaired cognition, and total dependence on staff for all ADLs. The facility’s own policy on call light accessibility stated that each resident would be reviewed for unique needs and preferences to determine any special accommodation needed to utilize the call light system, but this was not carried out for this resident.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents. During an initial tour, one resident was observed lying in bed in a room where several items of garbage were scattered on the floor and the wall across from the bed was splattered with a brown substance; a follow-up observation later that day showed the room remained in the same condition. In a separate room shared by two other residents, the floor on both sides of the room was littered with trash and debris and appeared as if it had not been mopped, one resident’s overbed table appeared dirty and discolored, and that resident’s nightstand had multiple dried spots of tube feeding formula on the top and dried formula that had dripped down the front. The other resident’s overbed table appeared dirty and sticky. When asked about room cleaning, a family member of one resident pointed to the trash on the floor and shrugged. A subsequent observation of the same room with the Maintenance Director showed that the floor, nightstand, and overbed tables remained in the same unclean condition, and the Maintenance Director acknowledged the room needed cleaning and that one overbed table needed replacement. The facility’s Homelike Environment policy stated that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Failure to Accurately Assess, Treat, and Document Changes in Condition and Hospice Services
Penalty
Summary
The deficiency involves failures to complete accurate assessments, document and act on vital signs and lab results, administer ordered medications and IV fluids, and communicate accurate clinical information to physicians for timely treatment or transfer, as well as failures in hospice communication and documentation. For one resident with dementia, seizures, and total dependence for ADLs, nursing staff documented a change in condition with shortness of breath and declining SpO2 after the spouse reported the resident did not look well and requested hospital transfer. The spouse reported that the physician initially refused transfer and threatened the nurse’s job, and that staff had difficulty obtaining accurate blood pressure readings. A photograph taken by the spouse showed a BP of 215/160, which the assigned RN confirmed seeing but did not document, stating they believed it was inaccurate and did not obtain a manual confirmation. The vital signs entered in the record instead showed a BP of 100/61, pulse 79, respirations 22, and SpO2 91% without a temperature, and the RN could not explain why a full set of vitals, including temperature, was not obtained or why the more abnormal values were not documented. EMS later documented the resident as hypoxic with SpO2 80% on room air, tachycardic at 140 bpm, hypotensive, febrile at 101.4°F, and with rhonchi in all lung fields, and the hospital documented sepsis, hypotension, tachycardia, and high fever on admission. For a second resident with coronary heart disease, schizophrenia, type II diabetes, and intact cognition, nursing notes documented nausea, vomiting, and poor oral intake, with an SBAR indicating a change in condition and a recommendation for blood tests. Labs drawn on one day showed elevated WBC and low RBC and hemoglobin, and were placed in the physician log and faxed, but there was no documentation that the physician reviewed the results or issued new orders. Subsequent notes documented a nosebleed and an order for a CBC for the following Monday, but no additional blood pressure readings were recorded on the day the resident was transferred to the hospital. EMS documented that the resident had hypotension persisting for three hours, with a reported BP of 80/59 prior to EMS arrival, and the hospital documented dehydration, low blood pressure with initial readings in the 50s and 70s/40s, a week of not eating or drinking, and vomiting. The agency nurse who arranged the transfer reported that they had difficulty obtaining blood pressures with two different machines, recalled one low reading but could not recall the value, and stated they were not aware of the prior vomiting and bleeding because, as an agency nurse, not all information was provided. For a third resident with cerebral infarction, acute respiratory failure with hypoxia, and hemiplegia, nursing notes documented a change in condition with audible fluid in the lungs, cough, elevated BP, and low-grade fever, with Tylenol and IM Lasix administered and the physician and family notified. Subsequent notes described shortness of breath and tachycardia, with an NP assessment of acute respiratory failure, multiple wounds, pneumonia, and decreased responsiveness, and orders to monitor vitals, SpO2, and for labs (CBC and CMP). The record contained no results for the ordered labs. Another NP note documented tachycardia, tachypnea, diminished breath sounds, a temperature of 99.6°F, heart rate 114, SpO2 98% on 3L, and an order for a 1L normal saline IV fluid bolus, but the MAR/TAR showed no documentation that the IV bolus was administered. A later MD note ordered a 1L normal saline IV bolus at 80 cc/hr and an increase in metoprolol to 50 mg twice daily, while the MAR/TAR showed that the new 50 mg dose was given in addition to the existing 25 mg twice daily, resulting in 75 mg twice daily being administered. Nursing notes documented episodes of shortness of breath, SpO2 dropping to 88% on 3L, and later to below 85% despite increasing oxygen to 5L and then a non-rebreather at 15L, with RR 26–30 and BP 168/89, but there was no documentation of the breathing treatments the RN stated were given, no physician order for those treatments, and no documentation of exact SpO2 values during the decline. The RN reported calling the physician and leaving a message without a callback, providing an undocumented breathing treatment without an order, and then calling 911; EMS found the resident unresponsive with GCS 3, SpO2 59% on NRB at 15L, respirations 30, and bilateral rales. The deficiency also includes failure to ensure hospice communication and care were provided and appropriately documented for a resident with anorexia, type II diabetes, dementia, and severe cognitive impairment who had an order to be admitted to hospice. The resident’s care plan identified a hospice focus with an intervention to collaborate with the hospice company and specified hospice visits with days and services. When asked, an RN located a thin binder near the nurse’s station, but the documents did not include the names and dates of hospice representatives visiting the resident. During an interview and record review with the DON and corporate clinical support nurse, hospice reported that the resident was to receive weekly visits from both a nurse and a CNA, and provided the caregivers’ names. However, front desk staff could not locate any hospice CNA sign-in sheets for the prior three weeks, and the corporate clinical support nurse stated it would be in the resident’s best interest to obtain new hospice services because the current hospice was not performing necessary visits. The facility’s hospice policy required that hospice provide the most recent hospice plan of care, that the facility communicate with hospice and document such communication, and that hospice information be available within the facility, but the documentation and sign-in records for this resident’s hospice services were incomplete or missing. Additionally, the surveyors requested an audit of actual administration times for the third resident’s January medications to clarify whether ordered treatments, including IV fluids and metoprolol dosing, were administered as scheduled. Multiple requests were made to the DON, administrator, and corporate clinical support nurse throughout the day, but the facility repeatedly reported that they did not have access to the audit data and did not provide the requested audit before the end of the survey. The facility’s change in condition policy required nurses to notify the physician when there is a significant change in physical status or a need to alter medical treatment, and to document assessments, notifications, interventions, and responses, but the records for the residents with changes in condition contained missing or incomplete vital signs, undocumented or uncompleted labs and treatments, and incomplete documentation of physician communication.
Failure to Provide Ordered Pressure Ulcer Treatments and Support Surfaces
Penalty
Summary
The facility failed to consistently implement ordered pressure ulcer treatments and preventive interventions for two residents with pressure injuries. For one resident with end stage renal disease, moderate protein-calorie malnutrition, dependence on dialysis, and prediabetes, surveyors observed on 1/13/26 that both feet were wrapped in gauze bandages dated 1/10, even though the Treatment Administration Record (TAR) showed the last documented treatments as completed on 1/9/26. Physician orders directed that the left heel deep tissue injury be cleansed with wound cleanser, treated with moist betadine gauze, covered with an ABD pad, and wrapped with kerlix, and that the right lateral ankle pressure ulcer be cleansed with wound cleanser, treated with Medihoney, covered with an ABD pad, and wrapped with kerlix, to be done on the night shift every Monday, Wednesday, and Friday. The January 2026 TAR showed that the ordered treatments for both the left heel and right lateral ankle were not completed on 1/12/26. When questioned, an LPN confirmed the dressings were dated 1/10, was unsure whose responsibility it was to complete the treatment, and could not explain why the 1/12/26 treatment was missed. For another resident initially admitted with coronary heart disease, paranoid schizophrenia, type II diabetes, and a psychotic disorder, the clinical record and hospital documentation showed stage 3 pressure injuries of the coccyx, sacrum, and right buttock, with hospital instructions for a low air-loss specialty mattress, turning every two hours with wedges, and avoidance of adult briefs to limit moisture. The resident’s care plan included an alternating pressure mattress for pressure ulcers on the coccyx related to immobility. Hospital records from two separate stays documented stage 3 pressure injuries and specified use of a low air-loss mattress and q2h turning with positioning devices. During observation, the resident was found lying on their back in bed without a low air-loss mattress and without a wedge in the room or bed; the resident reported having a painful wound on their bottom and wounds on their heels and recalled a hospital stay for the wound. A nurse later confirmed the resident did not have a low air-loss mattress and stated the wound nurse had said the wound was stage 2 and did not require it. The wound nurse reported that low air-loss mattresses are generally used for stage 3 or above and acknowledged not reviewing the hospital discharge notes that documented stage 3 pressure injuries and the need for a low air-loss mattress.
Failure to Implement Ordered Fall-Prevention Interventions After Repeated Bed Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a resident with dementia, osteoporosis, essential hypertension, moderately impaired cognition, and total incontinence. The resident required substantial/maximal assistance for bed mobility and transfers and had experienced a decline in ADL function, needing 1–2 person assistance with dressing, ambulating, and toileting. Progress notes documented two unwitnessed falls from bed on consecutive days, with the resident found on the floor near the bed on both occasions and unable to describe the events. The falls care plan, initiated earlier, identified the resident as at risk for falls due to decreased mobility, cognitive impairment, incontinence, and medication side effects. Despite this identified risk and the documented falls, required interventions were not in place at the time of surveyor observations. The care plan and IDT documentation called for bolsters or an overlay barrier to the mattress and a non-skid mat to the right side of the bed. However, on multiple observations, the resident was found lying on a regular mattress without bolsters or mattress overlay applied to the bed, and no non-skid mat was present on the floor. The mattress overlay was instead observed in the resident’s wheelchair. When interviewed, the assigned LPN did not know what the mattress overlay was or that it should be on the bed, and the unit manager initially stated the overlay was in place before acknowledging it was not. The DON stated interventions would not be documented until in place, despite the care plan and IDT notes already reflecting these interventions, and did not provide an explanation for their absence at the bedside.
Failure to Obtain Accurate Weights Resulting in Undetected Severe Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate weights and complete accurate nutritional assessments for one resident, resulting in a significant, previously unrecognized weight loss. The resident, who was cognitively intact, quadriplegic, and dependent on staff for all ADLs, was observed on multiple occasions to appear very thin, with visible ribs and thin arms and legs while lying in bed. Review of the clinical record showed a series of monthly weights from July through early January consistently documented around 148–149 lbs using a Hoyer lift. A weight of 121.6 lbs recorded in December was crossed out by an LPN with the notation “Incorrect Documentation,” and subsequent documentation again reflected a weight in the 149 lb range. When asked, the resident reported being weighed only occasionally and estimated his own weight at about 132 lbs, with a height of 6 feet 1 inch. On direct observation of staff weighing the resident with a mechanical lift, the resident’s actual weight was found to be 120.0 lbs, which was 29.6 lbs less than the most recently documented weight of 149.6 lbs recorded five days earlier. The RD reported that the resident’s weights had not triggered concern because they appeared stable in the record and stated she was in the process of working on the resident’s nutrition evaluation. After being informed of the observed 120.0 lb weight, the RD acknowledged that the resident did not look like he would weigh 149.6 lbs. The DON stated that CNAs obtained resident weights and entered them into the chart but did not provide an explanation for the large discrepancy between the documented and observed weights before the end of the survey. When surveyors requested a facility policy on weight management and obtaining accurate weights, no policy was provided prior to the end of the survey.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent during a medication administration observation, resulting in a 7.41 percent error rate. On 1/13/26 at 8:16 AM, an LPN prepared seven medications for resident R110, including Senna Plus 8.6-50 mg, and administered all seven medications to the resident. Later record review at 3:43 PM showed that R110’s physician order was for Senna 8.6 mg only, not Senna Plus, meaning the resident received an additional component (docusate) that was not ordered. The facility’s Medication Administration policy dated 8/7/23 required safe and accurate preparation and administration of medications according to physician orders, including the right medication. On the same date at 8:31 AM, another LPN prepared eleven medications for resident R70, including Geri-Kot 8.6 mg, and administered all eleven medications to the resident. Subsequent reconciliation of R70’s physician orders at 3:30 PM revealed an order for Sennosides-Docusate Sodium 8.6-50 mg, while the medication given (Geri-Kot) did not contain docusate. During an interview on 1/14/26 at 8:40 AM, the DON confirmed that Senna Plus could not be given when only Senna was ordered because it also contained docusate, and that Geri-Kot could not be given when Sennosides-Docusate was ordered because it lacked docusate. These two observed medication administration errors out of 27 opportunities resulted in a medication error rate above the 5 percent threshold.
Failure to Notify Family of New and Worsening Wounds
Penalty
Summary
The facility failed to consistently notify and update a resident's family regarding newly identified wounds and the worsening of existing wounds. The resident in question was admitted with significant medical conditions, including cerebral infarction and multiple myeloma, and was dependent on staff for all activities of daily living. Documentation showed that a new wound was identified on the resident's left hip, and a sacral wound progressed to a stage IV ulcer with exudate and bone exposure. Despite these developments, there was no documentation that the resident's emergency contact, their daughter, was notified about the new or worsening wounds. Progress notes indicated that the daughter was involved in care discussions and plan modifications, but specific notifications about the skin issues were not documented. The lack of communication became evident when the daughter called emergency services to have the resident transported to the hospital, where multiple wounds were identified, including a stage IV sacral ulcer and additional pressure wounds. Interviews with facility staff confirmed that family and physicians should be notified of such changes, but no evidence of notification was provided.
Failure to Report and Treat Decline in Pressure Ulcer
Penalty
Summary
A resident with diagnoses including cerebral infarction and multiple myeloma, who was dependent on staff for all activities of daily living, was admitted with a sacral stage IV pressure ulcer. On 10/24/25, a wound consultation documented the ulcer as full-thickness with moderate exudate but no signs of infection or inflammation. However, a skin issues note from the same day described purulent exudate and a moderately saturated dressing, indicating the presence of pus. The resident's care plan required monitoring for significant changes in the wound and notifying the physician of any such changes. Despite these findings, there was no documentation that the physician or wound clinician was notified of the purulent drainage. No further documentation regarding the sacral wound was found between 10/24/25 and 10/29/25, when the resident was transferred to the hospital. Hospital records indicated the presence of a stage IV decubitus ulcer with surrounding erythema and purulent discharge, and wound cultures revealed infection with Methicillin-Sensitive Staphylococcus aureus and Pseudomonas aeruginosa. Facility staff, including the wound nurse and DON, confirmed they were not informed of the purulent drainage prior to the resident's hospital transfer, and no additional explanation or documentation was provided.
Failure to Provide Consistent Indwelling Catheter Care
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate indwelling catheter care for a resident who was dependent on staff for all activities of daily living and had a history of cerebral infarction and multiple myeloma. Observation revealed the resident was in bed with a urinary Foley bag containing bright yellow, cloudy urine. Review of the medical record showed a physician order for catheter care every shift starting on 6/28/25, but there was no documentation that catheter care was consistently completed until 11/6/25. The Treatment Administration Record for November 2025 indicated staff documented catheter care twice daily, but there was no supporting documentation for the period from June to November 2025. Further review revealed that on 10/29/25, the resident was transported to the hospital, where the primary diagnosis was a urinary tract infection. Hospital records documented the presence of a chronic indwelling Foley catheter, a positive urinalysis for infection, and the need for intravenous antibiotics. Facility staff, including the Unit Manager and DON, were unable to provide documentation of catheter care for the resident during the specified period, and no further explanation or records were provided by the end of the survey.
Failure to Provide Consistent PEG Tube Care and Documentation
Penalty
Summary
The facility failed to ensure consistent and appropriate care for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who was dependent on staff for all activities of daily living and had diagnoses including cerebral infarction and multiple myeloma, experienced a clogged PEG tube, which was unsuccessfully addressed by nursing staff and ultimately required hospital intervention. Observations revealed soiled towels with large amounts of yellow and brown drainage left on and under the resident, and staff present during the observation were unable to explain the source of the drainage or why the towels had not been changed. There was no documentation in the medical record of abnormal drainage or incidents that morning. Further review of the resident's medical record showed a lack of consistent documentation regarding PEG care, and no current physician orders for PEG care were found. Previous orders for PEG site management had been discontinued without a documented date, and staff interviews confirmed uncertainty about the status of PEG care orders. The nurse assigned to the resident on the day of observation had not documented any PEG care or the events that occurred, despite being aware of the PEG tube leaking and the resident being sent to the hospital. These findings indicate a failure to provide and document necessary PEG tube care as required.
Failure to Maintain Sanitary and Homelike Environment in Common Areas
Penalty
Summary
Surveyors observed multiple unsanitary and unkempt conditions throughout the facility's first and second floor common areas, including dining rooms, a community room, and a community shower room. In the Two-West dining room, dried food spills, crumbs, debris, and personal items such as purses and tote bags were found in unlocked cabinets, along with old food and partially consumed beverages. The area also contained cleaning equipment, a baseball cap, food wrappers, and loose carpet pieces. The Two-East dining room had similar issues, with dried spills, food debris, insect webs, spiders, and unkempt cabinets containing personal items and used utensils with unknown substances. The kitchen area was noted to have liquid spills and dried food matter on surfaces. Common hallways on the second floor were observed to have moderate debris, spills, and an overall unkempt appearance, including sticky smudges and discarded items on windowsills. The first-floor community shower room, used by residents, contained soiled linens, a crumbled Hoyer lift tarp, and opened bathing wipes. The floor was dirty, with piles of human hair, broken razor caps, and insects present. The shower bed had tangled hair on its wheels, and the shower chair and seat were unclean, with multiple half-used shower gels and black discoloration in the creases. The first-floor community room, accessible to residents, staff, and visitors, had unlocked cabinets storing PPE and hypodermic syringes, as well as tables containing used bottles, electrical equipment, cracker crumbs, and a toothbrush. Food crumbs and debris were present throughout the carpeted room. Facility leadership, including the Nursing Home Administrator and Housekeeping Director, acknowledged the unkempt conditions during a tour of the affected areas.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident's medical records to the resident's authorized representative, as required by federal regulations and facility policy. The resident's representative had requested specific documents, including the most recent care plan, therapy notes, medication lists, and care guides, and had been waiting for over two months without receiving the requested records. Documentation showed that the representative communicated multiple times with facility administrators, expressing frustration over the delay and stating that no care conference would be scheduled until the records were provided. The facility's own grievance documentation noted the ongoing request and the representative's refusal to attend a care conference until the records were released. The resident in question had a diagnosis of dementia and was assessed as having severely impaired cognition, with the representative designated as the medical decision maker. Despite repeated requests and assurances from facility staff that the records would be provided, there was no evidence that the medical records staff received the request, and the records were not supplied until several months after the initial request. The facility's policy required access to records within 24 hours during business hours, but this was not met in this case.
Failure to Follow Physician Orders for Consults and Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed and that residents received appropriate treatment and care according to those orders and the residents’ preferences and goals. For one resident with chronic dermatological concerns, a nurse practitioner ordered a dermatology consult to address ongoing skin issues. Although the order was confirmed by nursing staff, the consult was never scheduled. The medical records/unit clerk admitted to not scheduling the appointment and could not provide a reason for the omission, despite the resident’s repeated requests and ongoing skin concerns. Another resident, who was readmitted from the hospital, did not receive multiple prescribed medications for several days. The resident reported going days without medications upon return to the facility. Medical record review confirmed that numerous medications, including those for seizures, pain, rash, and other chronic conditions, were not available or administered as ordered. Documentation showed repeated notations of medications being on order, awaiting pharmacy delivery, or not available, spanning several days and affecting a range of essential treatments. Interviews with facility staff, including the DON, revealed that there were established processes intended to ensure medication availability, such as using backup supplies and expedited pharmacy delivery. However, these processes were not effectively implemented, resulting in significant lapses in medication administration. The failure to schedule a specialist consult and to provide timely access to prescribed medications directly contravened physician orders and the standard of care expected for residents.
Failure to Obtain Consent and Coordinate Psychiatric Services for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide medically related social services by not obtaining informed consent from the resident representative prior to changing a resident's psychotropic medication regimen and by not coordinating necessary psychiatric services. The resident in question had diagnoses including dementia, paranoid schizophrenia, and anxiety disorder, and was prescribed Seroquel for management of psychiatric symptoms. Despite the resident's representative being designated as the medical decision maker, there was no documentation that consent was obtained or that the representative was informed prior to a reduction in the Seroquel dose. Progress notes and interviews confirmed that the medication change occurred without the required communication or consent. Additionally, the facility did not ensure ongoing psychiatric oversight for the resident. After a hospitalization and subsequent readmission, there were no documented psychiatry visits or medication reviews by a psychiatric practitioner for several months, despite the resident's complex behavioral health needs and ongoing use of antipsychotic medication. The facility's contracted psychiatrist was not permitted by the family to see the resident, and the psychiatric nurse practitioner was unable to see the resident due to scheduling conflicts with dialysis appointments. Virtual visits were mentioned as a solution, but had not yet been implemented at the time of the survey. Facility policy required social services to obtain informed consent for psychotropic medications and to coordinate psychiatric or counseling services. However, interviews with the DON and social worker confirmed that these responsibilities were not fulfilled. The social worker acknowledged that no conversation occurred with the resident representative regarding the medication change, and the required documentation and coordination of psychiatric services were lacking. This resulted in a failure to provide the necessary medically related social services to help the resident achieve the highest possible quality of life.
Failure to Obtain Ordered Oral Surgery for Resident
Penalty
Summary
A deficiency occurred when the facility failed to obtain and follow through with ordered dental services for a resident who required surgical extraction of two severely decayed molars. The resident, who had multiple medical diagnoses including diabetes, morbid obesity, heart disease, seborrheic dermatitis, and schizoaffective disorder, was seen by a dentist at bedside for tooth pain. The dentist documented that the resident needed surgical extractions of teeth #30 and #31 with sedation due to agitation, and provided a prescription for Clindamycin. The dentist also instructed that a referral to an oral surgeon be made for the extractions. Despite these orders, there was no evidence that the facility arranged the required referral or appointment with an oral surgeon. The DON, who ordered the antibiotic, could not confirm why the referral was not completed or documented, especially after the resident was sent to the hospital and subsequently readmitted. The facility's own policy required assistance with making dental appointments and documentation of any delays, but the record lacked evidence of these actions being taken for this resident.
Failure to Administer Medications Timely and per Resident Preference
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner and according to a resident's preferences and goals. One resident expressed complaints about receiving medications late, particularly noting that nurses would go on their breaks before administering medications, resulting in delays. The resident specifically mentioned feeling nervous about not receiving seizure medications on time, especially during the night. A review of the medication administration audit report revealed multiple instances where medications scheduled for specific times were administered significantly late, sometimes by several hours or even the following day. The facility's policy requires medications to be administered within one hour before or after the scheduled time, but the audit showed repeated deviations from this standard. The DON acknowledged awareness of the concerns regarding late medication administration for this resident.
Failure to Notify Responsible Party of Antipsychotic Medication Change
Penalty
Summary
The facility failed to notify the responsible party of a change in antipsychotic medication dosage for one resident. Specifically, the psychiatric service provider increased the resident's Seroquel dosage from 25 mg to 50 mg twice daily for mood instability and psychosis, as documented in a note dated December 2024. There was no documentation indicating that the resident's responsible party was informed of this medication change at the time it occurred. The facility's social services progress notes also lacked any evidence of notification, with the last entry predating the medication change by several months. The issue came to light when the resident's daughter contacted the facility administrator with concerns about the medication increase, expressing that the family was upset about not being informed. The facility's grievance form confirmed that neither the psychiatric service provider nor the social services department had contacted the responsible party until after the grievance was filed. During an interview, the assistant administrator acknowledged the lack of timely notification, and facility policy was reviewed, which requires informing residents and their representatives of changes in health status and treatment.
Failure to Include Responsible Party in Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were coordinated with the inclusion of the responsible party for one resident, as required. A complaint was received by the State Agency alleging that the resident's responsible party was not notified or included in care conferences. During an interview, the Social Worker stated that documentation of care conferences would be entered as a progress note in the resident's record. However, a review of the resident's Social Services Progress notes revealed that the last documented mention of a care conference was several months prior, and a review of the resident's assessments showed no evidence of care conferences. When the facility was asked to provide any documented evidence of care conferences for the resident, no documentation was provided by the end of the survey. The facility's own policy requires that care conferences be scheduled according to the MDS schedule, with invitations provided to the patient and/or responsible party, and that all attendees and discussions be documented. The lack of documentation and failure to include the responsible party in care conferences led to the deficiency cited in the report.
Failure to Supervise Use of Non-Medical Heating Pad
Penalty
Summary
Facility staff failed to provide appropriate supervision and accident prevention for a long-term resident with multiple medical conditions, including rheumatoid arthritis, ankylosing spondylitis, contractures, and intractable pain. The resident, who had intact cognition but required extensive assistance with mobility and ADLs, was found using a non-medical grade heating pad on their knees. The heating pad, brought from home by a family member, was applied by a CNA and left on for a couple of hours. The resident was unable to reach or adjust the heating pad independently due to physical limitations. There was no documentation in the resident's electronic medical record regarding the use of the heating pad, no physician order, and no care plan addressing its use. Facility staff, including the CNA, Unit Manager, RN, and DON, were unaware of the heating pad's presence or use, and facility policy did not permit such devices in resident rooms. The facility's risk management policy required the environment to be free from accident hazards and for residents to receive adequate supervision, but these protocols were not followed in this instance.
Failure to Provide Timely Incontinence Care and Maintain Resident Hygiene
Penalty
Summary
A deficiency occurred when a resident with a history of rheumatoid arthritis, ankylosing spondylitis, contractures, overactive bladder, and prior urinary tract infections did not receive timely incontinence care. The resident, who was cognitively intact and required extensive assistance with activities of daily living, reported not being changed overnight and was found lying in bed with a strong urine odor, wearing a soiled brief and lying on bedding with dried brown stains. Observations confirmed the presence of a strong odor and visible soiling of the bedding and mattress overlay, with staff interviews corroborating that the resident had not been changed for an extended period. Documentation and interviews revealed inconsistencies regarding care provided during the night shift. The CNA task report indicated the resident was last assisted with toileting in the early morning, with no further assistance documented for over 30 hours. Staff interviews indicated that the resident did not refuse care during the night in question, and there was no documentation of refusal in the medical record for that period. Both CNAs and the RN assigned to the resident acknowledged that the level of care observed was unacceptable, and the process for addressing refusals of care was not followed as documented in facility policy. The facility's policy required perineal care every two hours and documentation of all care provided, including attempts to re-approach residents who refuse care and notification of nursing staff. However, staff failed to provide timely incontinence care, did not document refusals or re-approach attempts, and did not communicate the resident's condition during shift changes. The lack of timely care and communication resulted in the resident remaining soiled for an extended period, with associated hygiene concerns noted by both the resident and hospital records.
Failure to Obtain Consent for Urine Toxicology Test
Penalty
Summary
The facility failed to adhere to a resident's right to decline a urine toxicity test, as evidenced by the case of a resident who was subjected to a urine sample collection without their consent. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15/15, reported feeling discriminated against and stated that the facility took a urine sample without permission and did not explain the reason for the test. The resident's clinical record showed orders for urine toxicology testing, but there was no documentation indicating the purpose of the test. The resident was observed to be alert and able to answer questions, and they expressed that staff had previously accused their visitors of smoking marijuana in their room, which they denied. Interviews with facility staff, including a social worker, nurse, physician, and the Director of Nursing, revealed a lack of awareness and documentation regarding the reason for the toxicology test and the facility's consent protocol. The nurse involved in the urine collection admitted to following physician orders without obtaining the resident's consent, as the resident was asleep at the time of collection. The physician who ordered the test cited concerns about the resident's behavior upon returning from a leave, but there was no documentation to support these concerns. The facility administrator acknowledged the absence of a specific policy on toxicology consent and confirmed that residents have the right to refuse treatment and testing, yet this right was not upheld in this instance.
Resident Involuntarily Secluded by Staff
Penalty
Summary
The facility failed to ensure freedom of movement for a resident, identified as R903, who was involuntarily secluded by staff members. On the date of the incident, R903 was placed behind three tables in the dining room, restricting their movement. This action was observed by other residents and staff members, who reported that the tables were positioned in a way that trapped R903, preventing them from moving freely. The incident was reported to the facility's administration the following day. R903 had a medical history that included generalized anxiety disorder, dementia, and delirium, and was known to exhibit wandering behaviors. The resident's care plan identified them as an elopement risk due to their wandering tendencies and confusion. Despite this, the staff members involved, including a CNA and an LPN, took measures to restrict R903's movement by placing them behind tables, which was not in line with the resident's care plan or their rights. Witnesses, including other residents and staff, confirmed the incident, and it was reported that the staff involved acted to avoid supervising R903. The facility's investigation revealed that the staff members involved were aware of the inappropriate nature of their actions, as evidenced by one CNA's attempt to persuade another to corroborate a false account of the event. The facility took disciplinary action against the staff involved following the investigation.
Failure to Timely Report Involuntary Seclusion Incident
Penalty
Summary
The facility failed to report an allegation of involuntary seclusion in a timely manner involving a resident diagnosed with generalized anxiety disorder, dementia, and delirium. The incident occurred when the resident was allegedly trapped between tables in the dining room by a CNA and an LPN, as reported by another resident who sent a picture to the Assistant Administrator. The Assistant Administrator received the report the following morning and informed the Administrator, who then initiated an investigation. The resident's movement was restricted, and the intent of the table positioning was believed to be to limit the resident's movement. The investigation revealed that two CNAs observed the incident but failed to report it. One CNA initially lied about the incident but later confirmed the restriction of movement during a follow-up interview. The facility's policy mandates immediate reporting of any abuse allegations to the Administrator or their designee, and the failure to adhere to this policy resulted in the delayed reporting of the incident to the State Agency. The facility's policy emphasizes providing care in an environment free from abuse, including involuntary seclusion, and requires immediate reporting of any allegations to the appropriate authorities.
Failure to Administer Prescribed Medication Leads to Hospitalizations
Penalty
Summary
The facility failed to administer an erythropoietin stimulating agent (ESA) as ordered by the physician for a resident, leading to multiple avoidable hospitalizations due to critically low hemoglobin levels. The resident, who had chronic normocytic anemia, chronic kidney disease, and other health issues, was supposed to receive the medication weekly. However, the medication was not administered for several months, despite the resident and their family repeatedly bringing the issue to the attention of the facility's administration. The resident's electronic medical record (EMR) showed that the medication was discontinued due to insurance non-coverage, and no alternative treatment was sought. The facility staff and providers were aware of the physician's order for the medication, yet there was no evidence of attempts to obtain it or communicate with the resident about the issue. The resident experienced multiple hospitalizations and blood transfusions due to low hemoglobin levels, which could have been prevented if the medication had been administered as ordered. Interviews with facility staff, including the nurse practitioner, unit manager, director of nursing, and administrator, revealed a lack of communication and follow-up regarding the resident's medication needs. The facility's policy required medications to be administered as prescribed, but this was not adhered to in the resident's case. The failure to provide the ordered medication resulted in significant distress and diminished quality of life for the resident.
Sanitation and Food Handling Deficiencies in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain the kitchen and pantry refrigerators on the 1st and 2nd floors in a sanitary manner, which had the potential to affect all residents consuming food. During an initial tour of the kitchen, pooled milk was observed on the floor near milk crates in the walk-in cooler, and the shelving rack used for storing spices and food items had a heavy buildup of grease, food debris, and dust. The 1st floor pantry refrigerator was heavily soiled with dried food spills, and the microwave was soiled with splattered food debris. The 2nd floor pantry refrigerator contained various undated and expired food items, including moldy meat and rice, a moldy bag of fruit, and other perishable foods that were not stored according to the facility's policy. Additionally, three male kitchen staff members were observed with beards but were not wearing beard restraints while prepping food, serving from the steam table, and assembling trays for lunch service. This was confirmed by the Dietary Manager, who acknowledged that all kitchen staff with beards should wear beard restraints. These observations indicate a failure to adhere to the 2017 FDA Food Code requirements for maintaining cleanliness and proper food handling practices in the facility.
Failure to Employ Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as required for facilities with more than 120 beds. During a recertification survey, it was identified that the facility, certified for 159 beds, did not have a full-time licensed social worker from the time a previous social worker's license expired until a new hire was made. This deficiency was noted to potentially affect all 122 residents residing in the facility. The facility's job descriptions for social work positions did not specify the licensing requirements for a full-time social worker in a facility of its size. Interviews with the Administrator revealed that the facility attempted to cover the gap with part-time and contingent social workers, but none were full-time or had valid licenses during the period in question. The Administrator acknowledged that the lapse in maintaining a full-time licensed social worker was due to oversight by Human Resources, which failed to track the expiration of licenses and ensure compliance with staffing requirements.
Failure to Employ Full-Time Social Worker and Provide Social Services
Penalty
Summary
The facility failed to establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan, which led to sub-standard quality of care. Specifically, the facility did not employ a qualified full-time social worker and failed to provide necessary medically related social services. This deficiency had the potential to affect all 120 residents of the facility. The facility was previously found to be out of compliance for similar issues during an abbreviated survey, but the concern was not addressed effectively. The Administrator was unaware of the lack of a full-time licensed social worker until it was brought to their attention. The part-time social worker's license had expired, and another part-time social worker from a sister facility was assisting, but neither was full-time. The facility's Human Resources department failed to monitor the social worker's licensing status. Additionally, there was a lack of coordination for mood and behavior management, psychotropic medication oversight, care plan development, and guardianship follow-through, which were not addressed by the facility's QAA and QAPI processes.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by observations of soiled floors, walls, and visible pest harborage. Complaints were reported to the State Agency regarding the facility's housekeeping staff not keeping the facility clean, including resident rooms. The facility's policies on maintaining a homelike environment and cleaning were not adhered to, as seen in the conditions of the residents' rooms and common areas. In one instance, a resident's room was observed with a dried substance splattered on the wall and a soiled tube feeding pole. Another resident's daughter reported concerns about the cleanliness of the room, which included a leaking CPAP machine, a used disposable wipe with fecal matter, and debris scattered throughout the room. The administrator acknowledged the poor conditions and confirmed that some areas needed replacement or repair, but no audits were maintained to monitor these issues. Further observations revealed unsanitary conditions in dining areas, with dirty tabletops, unkempt floors, and food trays with insects. The administrator and housekeeping supervisor confirmed these observations, indicating a lack of proper cleaning and maintenance. The facility was under receivership, and the administrator noted recent changes in housekeeping management, but these issues persisted, affecting the residents' living conditions.
Failure to Provide Adequate Social Services and Guardianship Coordination
Penalty
Summary
The facility failed to provide adequate medically-related social services to address the psychosocial and mental health needs of residents, specifically in the areas of mood and behavior management, patient advocacy, and guardianship coordination. This deficiency was identified during a survey, which revealed that the facility did not follow up on the psychosocial needs of three residents, R22, R25, and R117, who were reviewed for social services. The facility had previously been found out of compliance for similar issues during an earlier survey. For resident R22, the facility did not document or address the resident's behaviors, which were reportedly due to pain that the resident could not verbalize. Despite being on multiple psychotropic medications, there were no care plans implemented to monitor specific behaviors or symptoms, and no documentation from social services regarding the resident's behavior or medication use. The facility's policy required monitoring and documentation of behaviors and symptoms for residents on psychotropic medications, but this was not followed for R22. Resident R117 had severe cognitive impairment but no designated power of attorney or legal guardian, despite the need for one. The social services staff left a voicemail for the resident's granddaughter regarding guardianship but did not follow up further. Similarly, for resident R25, who was determined unable to make medical or financial decisions, social services recommended guardianship to the resident's daughter but did not document any follow-up after the initial recommendation. These lapses in social services coordination and follow-up contributed to the facility's failure to meet the residents' psychosocial and mental health needs.
Inadequate Documentation and Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate documentation and monitoring for a resident prescribed psychotropic medication, leading to prolonged unnecessary use. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and anxiety, was observed exhibiting behaviors such as yelling out. However, there was no documentation linking these behaviors to specific targeted symptoms that would justify the continued use of psychotropic medications. The facility did not attempt a gradual dose reduction (GDR) for the resident's medications, and the care plans lacked specific interventions or monitoring for the resident's behaviors. The resident's clinical records showed they were on multiple psychotropic medications, including antipsychotic, antianxiety, and antidepressant drugs, without adequate documentation of the behaviors these medications were intended to address. The facility's care plans were not implemented in a timely manner, and when they were, they did not include specific details about the resident's symptoms or behaviors. The facility's policy required documentation of behaviors and symptoms, but the records were incomplete, with some months showing no entries or lacking specific details. Interviews with the resident's family and healthcare providers revealed a lack of communication and understanding of the resident's behaviors. The Psych Nurse Practitioner and Attending Physician acknowledged the need for improvements but were unable to provide specific details about the resident's delusions or the rationale for continuing the medications. The facility's failure to document and monitor the resident's behaviors and the effectiveness of the psychotropic medications resulted in a deficiency in care, as outlined in the facility's policy for behavior and psychotropic medication monitoring.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as R22, who was observed seated behind the nursing station and repeatedly yelling out loudly. Despite attempts by staff to redirect the resident with a magazine and informing them that their daughter was out of town, the resident continued to yell. During these episodes, another resident in a nearby room yelled back for R22 to "Shut-up," and staff members were observed laughing immediately after this interaction. The staff did not verbally respond or attempt to redirect the resident who yelled at R22, nor did they address the situation appropriately. R22, who had severe cognitive impairment and was diagnosed with unspecified dementia, epilepsy, generalized anxiety disorder, major depressive disorder, and vascular dementia, was not treated with the dignity and respect outlined in the facility's policy. The facility's policy mandates that residents be treated with kindness, dignity, and respect, and any violations should be reported to the Director of Nursing Services or the Administrator. However, during the surveyor's observations, staff failed to address the inappropriate behavior directed at R22, and the facility's video surveillance was inadequate to provide clear evidence of the incident.
Failure to Provide Appropriate Mobility Equipment for Resident
Penalty
Summary
The facility failed to provide an appropriate wheelchair or Geri-chair for a resident with significant cognitive impairment and multiple medical conditions, including respiratory failure, stroke with right hemiplegia, and a tracheostomy tube. The resident was dependent on staff assistance for mobility and transfers and expressed a desire to get out of bed. However, observations revealed that the resident did not have a suitable chair in their room to facilitate this. Despite the resident's repeated requests to get out of bed, staff were unaware of the lack of a Geri-chair, and the resident remained in bed for several days. Interviews with staff, including an LPN and CNAs, indicated a lack of awareness and communication regarding the resident's need for a Geri-chair. The Director of Rehabilitation acknowledged the limited availability of Geri-chairs and confirmed that the resident used one. The Director of Nursing stated that staff were expected to assist residents in getting out of bed as they chose, but multiple observations showed this was not happening for the resident in question. The facility's policy on accommodation of needs was requested but not provided before the survey exit.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances reported by a long-term resident, identified as R104, and their family. R104, who had intact cognition, had multiple hospitalizations and was diagnosed with chronic normocytic anemia, CKD, respiratory failure, dry gangrene, and diabetes. The resident reported not receiving a prescribed medication to maintain hemoglobin levels for several months, despite addressing the issue with the facility administration and attending physician. The resident's family also raised the concern during a meeting with the facility administration and followed up with emails, but the issue remained unresolved. The facility administrator did not document any grievances for R104, despite multiple communications from the resident and their family. The family sent follow-up emails to the administrator on several occasions, expressing concerns about the medication, insurance paperwork, and therapy. The administrator responded once, acknowledging the emails but providing no specific resolution. The administrator claimed they were not present when the events occurred and were trying to get answers, but no further follow-up was conducted, and the medication issue persisted. During interviews, the administrator acknowledged the meeting with R104 and their family but dismissed the family's involvement as meddling. The administrator described the facility's grievance process, which involves staff initiating grievance forms and department leaders addressing concerns. However, the administrator did not explain why grievances from R104 or their family were not documented or addressed, indicating a failure to adhere to the facility's grievance policy.
Failure to Complete Annual OBRA Level II Evaluation
Penalty
Summary
The facility failed to complete an annual OBRA Level II Evaluation for a resident who was reviewed for PASARR. The resident was admitted with conditions including hemiparesis following a stroke, heart failure, diabetes, hypertension, vascular dementia, and bipolar disorder. Despite a Brief Interview for Mental Status indicating the resident was cognitively intact, there was no evidence of a Level II evaluation being completed. Instead, two 3877 forms were submitted, but the necessary 3878 dementia exemption form was not completed for either date. The Assistant Administrator indicated they were waiting for a physician's signature for the 3878 form, while the Social Services Coordinator was unable to locate the form in the resident's medical record or electronic portal. The Coordinator was also unaware of the option to reach out to the local OBRA Coordinator for assistance. The Social Services Coordinator acknowledged the failure to submit the forms timely, as the current forms were due by July 2024, and could not provide documentation of an exemption or a Level II PASARR.
Failure to Develop Resident-Specific Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop resident-specific comprehensive care plans for a resident with behavior-emotional needs and the use of psychotropic medications. The resident, who was observed yelling loudly while seated in a wheelchair, had a history of unspecified dementia with mood disturbance, generalized anxiety disorder, depression, and severe vascular dementia with agitation. Despite these diagnoses, the care plans lacked specific details about the resident's mood and behaviors, as well as targeted behaviors to monitor or approaches to de-escalate the resident. The care plans for the resident's use of psychotropic medications were not implemented until several months after the resident's readmission. The facility's policy on care planning, dated January 2020, did not ensure that care plans were resident-specific. During an interview, the Corporate Clinical Nurse indicated that the interdisciplinary team was responsible for ensuring care plans were specific to the resident's needs, but this was not reflected in the care plans reviewed.
Failure to Secure Smoking Materials in Non-Smoking Facility
Penalty
Summary
The facility failed to secure smoking materials for a resident, R15, who was reviewed for smoking, despite being a non-smoking facility. During an entrance conference, the administrator stated that the facility did not have any current smokers. However, observations and interviews revealed that R15, who had a history of nicotine dependence and other medical conditions, kept smoking supplies hidden in their room and smoked without staff assistance or monitoring. R15 was observed sitting in their power wheelchair and reported that they would go out to smoke, keeping cigarettes and a lighter in their coat pocket. Staff, including a CNA, were aware of R15's smoking habits, yet no proper supervision or security of smoking materials was in place. The facility's records, including physician and social worker notes, indicated that R15 was a current smoker and had been informed of the non-smoking policy. Despite this, the unit manager and administrator were unaware of R15's smoking activities until notified by surveyors. The unit manager initially claimed there were no smokers in the facility, and the administrator acknowledged the concern only after being informed of the observations. The lack of proper supervision and failure to secure smoking materials posed a potential risk of burns from smoking materials that were unsecured.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an observed error rate of 8.33%. This deficiency was identified during a medication administration observation involving three residents. The Licensed Practical Nurse (LPN) was observed administering enteric-coated aspirin instead of the prescribed chewable aspirin to three residents. Specifically, the LPN crushed and administered enteric-coated aspirin to two residents and administered it without crushing to another resident, contrary to the physician's orders. The Director of Nursing acknowledged that the LPN should have administered the correct medication as ordered and that enteric-coated medications should not be crushed for administration. The facility's policy on medication administration, dated December 2019, requires medications to be administered in accordance with the physician's written orders.
Lack of Access to Survey Results for Residents and Visitors
Penalty
Summary
The facility failed to ensure that residents and visitors had access to previous survey results, which resulted in them being uninformed of deficiencies identified in the facility. The facility's policy on Resident Rights, dated 7/11/2018, states that residents have the right to examine the results of the Nursing Center's most recent survey and the plan of correction prepared in response. However, a review of the survey information binder revealed that there was no documentation available from surveys conducted on 12/20/23, 5/8/24, 6/17/24, and 7/30/24 since the last recertification survey on 10/12/23. During environmental rounds, the Administrator confirmed that the binder had not been updated and mentioned that an Assistant Administrator, hired on 9/9/24, was responsible for this task. The Administrator did not provide an explanation for who was responsible for updating the binder prior to the recent hire. Further review of the binder on 10/2/24 showed no updates since the discussion with the Administrator.
Violation of Resident's Right to Self-Determination
Penalty
Summary
The facility failed to promote self-determination and respect the rights of a resident, identified as R802, who was his own responsible party, to make his own decision to leave the facility temporarily. On December 30, 2023, R802 attempted to leave the facility to visit his storage unit due to concerns about his belongings after being evicted from his apartment. Despite having intact cognition and no legal guardian, facility staff prevented him from leaving, citing the need for a guardian's permission and a physician's approval. The staff threatened to commit him to a psychiatric unit if he attempted to leave, causing the resident to feel angry and distressed. R802's clinical record showed no evidence of a legal guardian or a competency evaluation as of the date of the incident. Interviews with facility staff, including the social services director and the nurse practitioner involved, revealed a lack of awareness regarding R802's legal status and rights. The nurse practitioner, NP 'N', instructed staff to prevent R802 from leaving and to call the police if he persisted, based on information from the social worker. However, there was no documentation supporting the claim that R802 was incompetent or had a guardian at the time. The facility's actions were based on incorrect assumptions about R802's legal status, leading to a violation of his rights. The social services director and the administrator, who were not present during the incident, later confirmed that R802 did not have a legal guardian and had the right to leave the facility. Despite this, the facility's failure to verify R802's legal status and respect his autonomy resulted in a deficiency related to resident rights and self-determination.
Failure to Provide Accurate Wound Care
Penalty
Summary
The facility failed to conduct a thorough and accurate skin assessment and did not clarify discharge instructions from the hospital for a resident with a wound. Upon admission, the resident, who had undergone a procedure on his left leg, reported severe pain and dissatisfaction with the care provided. The hospital discharge instructions included specific wound care orders, such as daily packing changes and the application of silver sulfadiazine cream, which were not accurately reflected in the facility's orders. The facility's records showed inconsistencies in wound treatment administration, with several instances where the treatment was not provided as ordered. The Medication Administration Report (MAR) indicated missed treatments, and there was no documentation explaining the omissions. Additionally, the facility's wound care provider and the orthopedic surgeon had conflicting assessments and treatment recommendations, which were not reconciled, leading to the resident receiving two different treatments simultaneously. Interviews with the Director of Nursing (DON) revealed a lack of clarity and communication regarding the resident's wound care needs. The DON admitted to not fully reviewing the hospital records and was unaware of the incision and drainage procedure. The facility's policy on skin monitoring and management was not followed, as the initial skin assessment did not document the wound accurately, and the special instructions from the hospital were not incorporated into the treatment plan.
Failure to Provide Physician-Ordered Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as R802, who required physician-ordered treatment from a podiatrist. Upon observation, R802 was found with very long, yellow, and thick toenails, and a painful, large, thick, yellow bump on the bottom of his left foot. Despite multiple physician orders for podiatry consultations and treatments, there was no evidence that R802 had been seen by a podiatrist since his admission. The resident expressed confusion and pain due to the lack of podiatric care, indicating that his toenails were causing discomfort and difficulty in walking. The facility's records revealed several physician orders for podiatry services, including nail debridement, which were not followed. The orders spanned from November 2023 to July 2024, yet there was no documentation of any podiatry visits. Interviews with the Social Services Director and the Director of Nursing indicated that the resident had not signed a consent form for podiatry services, allegedly due to concerns about financial responsibility. However, there was no documentation of the resident's refusal or any attempts to clarify his financial concerns. The Administrator confirmed the lack of documentation regarding the resident's refusal and the absence of a facility policy on podiatry and foot care. The resident reported that the process was not explained to him upon admission, and he was only recently informed that the podiatrist would visit the facility. Despite expressing a desire to see the podiatrist, the resident remained without the necessary care, leading to ongoing pain and difficulty walking.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for two residents, R802 and R804, as required to help them achieve the highest possible quality of life. For R802, a veteran with peripheral vascular disease and a history of traumatic brain injury, the facility did not adequately address his concerns about guardianship and discharge planning. Despite being alert and oriented, R802 was told he had a guardian without being provided any verification, and his requests for guardianship papers were ignored. The facility also failed to ensure timely competency evaluation and did not pursue guardianship until eight months after it was first considered necessary. Additionally, R802's need for podiatry care was not addressed, and there was no evidence of efforts to verify his eligibility for Veterans benefits. R804, who had lupus, dementia, and paranoid schizophrenia, was readmitted to the facility on hospice status without a legal guardian or advance directives in place. The facility failed to allow R804's legal guardian to sign a do-not-resuscitate order, and there was no documentation of R804's medical treatment wishes prior to becoming incapacitated. Despite the family member being granted full guardianship, the facility did not revisit R804's code status, and there was no evidence of communication regarding the resident's end-of-life wishes. The facility's social services director and staff did not fulfill their responsibilities to provide necessary social services, coordinate ancillary services, and advocate for resident rights. The lack of timely action and documentation regarding guardianship, competency evaluations, and discharge planning contributed to the deficiencies identified in the report. The facility's failure to ensure residents' rights and needs were met resulted in significant oversights in the care and support provided to R802 and R804.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for residents on the second floor, as observed during an unannounced investigation. The investigation revealed strong odors, rusted equipment, and unmopped floors with visible footprints. Specific rooms were found in unsanitary conditions, with sticky floors, trash, and debris scattered throughout. Residents R505, R508, R509, and R510 were directly affected, with their rooms exhibiting various cleanliness issues, such as dried substances, loose fixtures, and stained privacy curtains. Interviews with residents indicated varying levels of awareness about the cleanliness of their rooms, with some residents having impaired cognition. Housekeeping staff, including Housekeeper 'B' and Housekeeping Supervisor 'A', were interviewed regarding their cleaning responsibilities. Housekeeper 'B' confirmed the requirement to clean each resident's room, including emptying trash, sweeping, mopping, and cleaning high-touch surfaces. However, the observed conditions indicated a failure to meet these standards. Housekeeping Supervisor 'A' acknowledged the unacceptable state of the rooms and attributed it to issues with certain housekeepers not thoroughly cleaning. The supervisor also noted that the maintenance staff was responsible for cleaning the internal components of heating and cooling units, while housekeeping was responsible for the external components. Additional observations in the 2 East Lounge/Dining Room revealed a safety hazard with a hole in the carpet exposing a receptacle box with wires and cables. Staff interviews indicated the hole had been present for about a month, and the Maintenance Director was unaware of the issue until informed. The Administrator was also questioned about the hole and had no explanation for its prolonged presence. The facility's policy on maintaining a clean environment was reviewed, highlighting the requirement for daily cleaning and disinfection of patient care areas, which was not adhered to in this instance.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency within the required time frame. The incident involved two residents, R501 and R502, where R502, who had a history of aggressive behavior and severely impaired cognition, entered R501's room and physically assaulted her. Despite the night shift staff being present, they did not intervene to prevent further harm. The incident was reported to the police by the day shift RN at 10:30 AM, but the State Agency was not notified until 10:33 AM, approximately six and a half hours after the incident occurred. R501, who had intact cognition, was assaulted by R502 around 4 AM. R502 entered R501's room multiple times and punched her in the face. The incident was documented by LPN 'C' at 5:41 AM, who notified the DON and ADON. However, the police were not contacted until later in the morning by RN 'H', who was the oncoming day shift nurse. The facility's investigation noted that the incident was discovered at 8:30 AM, and the State Agency was contacted at 10:33 AM. Interviews with the staff revealed communication lapses and delays in reporting the incident. LPN 'C' reported the incident to the DON and ADON but did not contact the police. The DON was informed of the incident at 9:00 AM after discovering a missed call from the ADON. The Administrator, who was the Abuse Coordinator, was contacted at 4:30 AM but did not answer the call, and no message was left. The facility's policy required immediate reporting of abuse allegations to the Administrator or their designee, and to the State Agency within two hours, which was not adhered to in this case.
Inadequate Supervision Leads to Resident Assault
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of wandering and aggressive behaviors, leading to multiple incidents of assault on another resident. The resident with dementia, identified as R502, entered the room of another resident, R501, multiple times during the early morning hours. Despite the presence of night shift staff, R502 was able to enter R501's room, attempt to get into her bed, and physically assault her by punching her in the face. The staff did not intervene effectively to prevent these repeated intrusions and assaults. R502 had a documented history of wandering into other residents' rooms and exhibiting aggressive behaviors, including previous incidents of physical aggression towards his wife, who was also a resident at the facility. Despite this history, there were no new interventions implemented after the initial care plan was created to address his wandering behaviors. The facility's staff, including CNAs and LPNs, were aware of R502's behavior but failed to take appropriate actions to prevent further incidents. The Director of Nursing (DON) was not informed of the full extent of R502's actions on the night of the incident. The incident was reported to the police later in the morning, and R502 was eventually discharged to the hospital. However, the facility's failure to implement adequate supervision and interventions for R502's known behaviors resulted in the repeated assault of R501, who expressed concern for her safety. The lack of effective monitoring and response from the staff allowed R502 to continue his aggressive behavior unchecked, highlighting a significant deficiency in the facility's supervision and safety protocols.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents' rights to be free from physical and verbal abuse by staff and other residents. One incident involved a Certified Nursing Assistant (CNA) who was observed on video slapping a resident seated in a wheelchair. The incident was reported by a housekeeper who witnessed the abuse and was confirmed by the facility's Administrator and Director of Nursing (DON) after reviewing the video footage. The resident involved had severe cognitive impairments and exhibited physical and verbal behaviors, including rejecting care at times. The CNA was terminated, and the incident was reported to the police, resulting in charges against the CNA for Vulnerable Adult Abuse and Assault and Battery. The facility's investigation substantiated the abuse, and the CNA's nurse aide certificate was intended to be revoked by the State Agency. The current Administrator was not aware of the incident as they were not employed at the facility at the time it occurred. The video footage clearly showed the CNA approaching the resident, attempting to grab her hand, and then slapping her across the mouth when she swatted the CNA's hand away. The resident's clinical record indicated diagnoses of bipolar disorder, anxiety disorder, and dementia, with a Minimum Data Set (MDS) assessment revealing severely impaired cognition and behavioral issues. Another incident involved resident-to-resident physical abuse, where one resident hit another in the back of the neck. The victim, who was moderately cognitively impaired, reported that the perpetrator frequently told him he was not welcome in the activities room. The perpetrator, who was cognitively intact, admitted to hitting the victim after a verbal altercation. Staff members, including a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA), confirmed the incident and provided additional context about the residents' behaviors. The facility's policy on abuse and neglect emphasized the importance of providing care in an environment free from any type of abuse, defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy also clarified that willful actions are deliberate, regardless of the intent to inflict harm. The Director of Nursing (DON) and Regional Nurse Consultant were unaware of the victim's hostile behaviors and indicated the need for staff to document such behaviors for follow-up. The facility's failure to protect residents from abuse by staff and other residents highlights significant deficiencies in ensuring a safe and respectful environment for all residents.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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