Regency, A Villa Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Taylor, Michigan.
- Location
- 12575 S Telegraph Rd, Taylor, Michigan 48180
- CMS Provider Number
- 235333
- Inspections on file
- 40
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Regency, A Villa Center during CMS and state inspections, most recent first.
A resident with a surgically repaired femur fracture, anxiety, and left eye blindness was discharged home without a documented discharge care plan or discharge summary, despite social work notes indicating a plan to return home with HHC. Progress notes over more than a month contained no evidence of discharge planning, and the facility’s “My Transition Home-Discharge” form was largely blank, missing the HHC agency phone number, follow-up appointment information, and sections for contact, medications, nursing instructions, dietary needs, and discharge instructions. After discharge, the resident reported that the paperwork lacked contact information for HHC, resulting in a week-long delay in connecting with services and multiple calls back to the facility to obtain correct information, while leadership later acknowledged the incomplete documentation and absence of a formal discharge plan.
The facility failed to complete required discharge summaries and provide essential transition information for two residents. One resident discharged to a family member had a discharge summary form with all summary-of-stay, continuing care, special instructions, and additional information sections left blank despite significant medical conditions. Another resident discharged home after surgery reported difficulty contacting home care because the discharge paperwork lacked phone numbers; this resident’s record contained no discharge summary or recapitulation of stay, and the transition form was missing contact information, medication details, nursing instructions, dietary information, discharge instructions, and follow-up appointment information. The SW and DON confirmed the absence of required discharge documentation, contrary to facility policy.
A resident with ESRD, dementia, psychotic and mood disturbances, anxiety, and schizophrenia exhibited frequent agitation and anger, particularly around hemodialysis treatments, and required significant assistance with daily activities. The dialysis center repeatedly reported the resident’s agitated behaviors and requested that medications be given before treatments, documenting agitation on communication forms and calling the facility multiple times. The facility failed to maintain complete dialysis communication forms in the EMR, did not document telephone communications from the dialysis center, and did not ensure an ordered antianxiety medication was available before a scheduled dialysis session. The resident’s dialysis care plan lacked person-centered goals and interventions to address dialysis-related behavioral needs, and the facility did not consistently follow its own policy requiring written communication and review of pertinent information with the dialysis provider.
A resident's hydrocodone medication was misappropriated by an LPN, resulting in 28 missing doses. The DON confirmed the loss and acknowledged a lack of documentation for staff education on narcotic reconciliation, as well as no evidence of training for agency nurses or follow-up audits to ensure compliance.
A resident with hemiplegia and a history of stroke eloped from the facility by climbing over a patio fence. Although the family and police were notified and the resident was found safe, the facility did not report the incident to the State Agency as required by policy and law.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with psychiatric and cognitive disorders became agitated and aggressive, leading to administration of Haloperidol and transfer to a hospital on a psychiatric petition. Required transfer documentation, including details of the resident's health status, transfer arrangement, and destination, was not completed or included in the medical record, as confirmed by the DON and facility leadership.
A resident with multiple psychiatric diagnoses exhibited severe behavioral disturbances, leading to a psychiatric petition and hospital transfer. The incident, including staff interventions and the use of emergency medication, was not documented in the EHR as required, despite facility policy mandating such documentation.
A resident with severe cognitive impairment and a history of Parkinson's and Alzheimer's disease experienced a fall and was sent to the hospital for evaluation. Upon return, orders for a Lidocaine 4% topical pain patch and a urinalysis were not transcribed or completed, resulting in the resident not receiving the prescribed pain management or the required laboratory test. Review of records and staff interviews confirmed these omissions.
A resident was not treated with dignity during mealtime assistance as a CNA stood over them while feeding, causing food to drop onto their clothing. The resident was seated in a Broda Chair, and staff had not been trained to feed residents in this type of chair, preventing them from sitting at eye level. The facility's policy requires feeding with attention to safety, comfort, and dignity.
A resident reported that their packages were being opened by staff without consent, leading to feelings of anger and disrespect. Interviews with facility staff confirmed that packages are routinely inventoried before delivery, which contradicts the facility's policy that staff should not open mail without resident permission. The resident, who has intact cognition and several medical conditions, highlighted this breach during a Resident Council meeting.
A resident with a traumatic brain injury was found lying on soiled linens for two consecutive days, despite facility protocols requiring linen changes when soiled and on shower days. The resident expressed dissatisfaction, and staff interviews confirmed the expectation to change linens as needed, highlighting a failure in maintaining a clean and homelike environment.
A resident with intact cognition reported missing clothing items after donating some to the Concierge. The facility failed to document or address the grievance, as the Concierge did not fill out a grievance form or notify the abuse coordinator, contrary to the facility's grievance policy.
An LPN failed to properly position a resident during medication administration, leading to a medication error. The resident, with a history of multiple health conditions, was lying flat in bed, causing pills to spill. The LPN did not identify the spilled medication or contact the physician for further instructions, as confirmed by the DON.
Three residents in the facility did not receive adequate assistance with activities of daily living, resulting in unkempt appearances and unmet hygiene needs. One resident had matted hair and an unshaven beard, with no documentation of scheduled showers being completed. Another resident expressed a desire for shaving assistance, which was not routinely offered. A third resident reported not receiving a shower for two weeks, with inaccurate shower logs failing to reflect the lack of care. The facility's policy for regular showers and accurate documentation was not followed.
A resident's nebulizer mask was improperly stored by hanging on a dresser drawer, contrary to facility policy, which requires storage in a dated plastic bag. The resident, diagnosed with COPD and having intact cognition, was unaware of the proper storage procedure. Both an LPN and the DON acknowledged the correct storage practice, highlighting a failure to follow established respiratory care standards.
Two residents experienced unsafe conditions in the facility. One resident's bathroom lacked warm water and had structural issues, while another resident's call light system had exposed wires. Despite work orders and plans for remodeling, these issues were not promptly addressed, leading to dissatisfaction and potential harm.
The facility failed to provide annual dementia management and abuse prevention training for a CNA, as required by policy. The CNA's training records from the past year lacked documentation of these essential trainings. Both the ADON and DON confirmed the absence of training records and acknowledged the expectation for CNAs to complete yearly training. The facility policy requires a minimum of 12 hours of training per year, including these topics.
The facility failed to provide timely and accurate urinary catheter care for two residents, leading to potential complications. One resident was admitted with a catheter, but care orders were delayed by nine days. Another resident, admitted with a catheter from the ER, reported no initial care and was later hospitalized for a UTI. This highlights a deficiency in catheter management.
A resident was denied the right to discharge AMA from a facility, causing psychological distress. Despite being alert and oriented, the resident was placed in a lockdown dementia unit and deemed incompetent by facility staff without a judicial ruling. The Ombudsman intervened, educating the DON on resident rights, leading to the resident's discharge.
The facility failed to ensure appropriate transfer documentation for a resident transferred to the hospital for hip surgery. The clinical record lacked essential information about the resident's transfer, including their destination, condition, and transportation method, which is necessary for continuity of care.
The facility failed to consistently obtain a resident's blood pressure readings prior to administering antihypertensive medications as ordered, leading to potential risks. The DON acknowledged the oversight, confirming that blood pressure should be taken and documented before medication administration.
The facility failed to complete discharge instructions and recapitulation of stay for a resident, missing critical information such as diagnosis details, lab values, and care plan goals. The DON acknowledged the incomplete documentation, which is essential for continuity of care. The facility's guideline for discharge summary was not followed.
The facility failed to conduct weekly skin observations for two residents and a Braden skin assessment for one resident, leading to potential undetected skin care needs. The DON confirmed the lack of documentation and overdue assessments.
The facility failed to maintain proper sterile hygiene practices, hand hygiene, and glove usage during tracheostomy care for a resident. An LPN did not follow sterile techniques, failed to perform proper hand hygiene when switching gloves, and did not remove dirty gloves throughout the procedure. The resident had medical diagnoses including quadriplegia, anoxic brain damage, and a tracheostomy, and was dependent on assistance for hygiene.
Failure to Complete and Document Effective Discharge Planning and Instructions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and document an effective discharge plan of care for one resident, resulting in delayed initiation of home health care services and potential delay of follow-up appointments. The resident was admitted with multiple diagnoses, including a surgically repaired left femur fracture after a fall at home, anxiety, and left eye blindness, and was discharged home. Although a social work note early in the stay documented that the resident’s discharge plan was to return home, there was no comprehensive discharge care plan or discharge summary in the electronic health record, and progress notes over more than a month did not show evidence of discharge planning. Subsequent social work documentation indicated that the resident received a Notice of Medicare Non-Coverage and that the plan was for discharge home with home health care, and that the resident was discharged home without DME because it was reportedly already available at home. However, the required discharge planning elements outlined in the facility’s own Transfer and Discharge Guideline—such as evaluation of discharge goals, preferences, care needs, and development of a person-centered discharge care plan by the interdisciplinary team—were not reflected in the record. The resident’s needs and discharge plan were not documented as required, and there was no documented discharge summary including post-discharge services, follow-up details, or medication reconciliation. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health care agency’s phone number, information on follow-up appointments, and entries in sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The resident later reported that it took a week after returning home to reach anyone from home care, and that the paperwork provided at discharge did not include any phone numbers, leading them to call the facility social worker multiple times to obtain the correct contact information. The Director of Social Services and the DON both acknowledged that the transition form was incomplete and that there was no discharge care plan or discharge summary documented for this resident.
Failure to Complete Discharge Summaries and Provide Essential Transition Information
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries, including a recapitulation of stay and essential discharge information, for two residents. One resident, who was being discharged to stay with her daughter, had a Recapitulation of Stay (Discharge Summary) form dated the day of discharge that was largely blank. Sections 1a–8, which should have contained the summary of stay, continuing care information, and special instructions or precautions, were not completed. The Additional Information section, which should have included contact information, was also blank, leaving the discharge summary incomplete despite the resident’s multiple diagnoses, including cerebral infarction affecting the dominant side and a fractured left humerus. Another resident, discharged home after surgical repair of a fractured left femur and with additional diagnoses including anxiety and left eye blindness, did not have any Recapitulation of Stay (Discharge Summary) form or discharge summary in the EHR. The resident reported that home care had been set up but that it took a week after returning home to reach anyone, and the discharge paperwork provided did not include phone numbers for the home health care agency. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health agency phone number, follow-up appointment information, and entries in the sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The SW and DON both confirmed, upon review of the record, that there was no discharge summary or recapitulation of stay, despite the facility’s written policy requiring a discharge summary that includes a recapitulation of the resident’s stay and medication reconciliation.
Failure to Coordinate and Document Dialysis-Related Communication and Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective, documented communication and coordination with an outpatient dialysis center for a resident receiving hemodialysis, resulting in missed communication needed for continuity of care. The resident, who had end stage renal disease, dysphagia, dementia, psychotic disturbance, mood disturbance, anxiety, and schizophrenia, was observed on multiple occasions to be anxious, restless, angry, and agitated, including when preparing to leave for dialysis. The resident required assistance with most daily activities and had severe cognitive impairment and unclear speech. The dialysis care plan dated 6/9/24 did not include person-centered goals or interventions that adequately addressed the resident’s dialysis-related needs, including behavioral issues associated with dialysis treatments. Dialysis communication forms from the dialysis center documented agitation during treatments on specific dates, and the dialysis center reported that the resident frequently arrived very angry and anxious, requiring up to 40 minutes to calm before treatment. Dialysis staff stated they had repeatedly notified the facility, both by phone and in writing, about the resident’s behaviors and the need for medications to be administered prior to dialysis. On one date, an RN reported that an ordered antianxiety medication was not available at the facility before the resident left for dialysis and that a prescription was needed to obtain it, but the RN did not document the telephone communication with the dialysis center. Requested dialysis communication forms for several treatment dates were not present in the electronic medical record and could not be produced when requested by the DON, who acknowledged documentation was an area needing improvement. The facility’s own dialysis guideline required written communication and review of pertinent information between the dialysis provider and the facility, which was not consistently implemented for this resident.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically the loss of 28 doses of hydrocodone, a schedule II narcotic pain medication. The incident involved an LPN who was identified as having taken the medication after a nurse discovered the medication cartridge was empty and the pharmacy would not refill it due to it being too soon. A review of the narcotic count confirmed the missing doses. The resident involved reported receiving all pain medications and had no complaints regarding administration at the time of the interview. The Director of Nursing (DON) confirmed the misappropriation and stated that all nurses had been educated on narcotic reconciliation procedures. However, there was no documentation to support that this education had occurred, nor was there evidence that agency nurses had received any such training. Additionally, the DON acknowledged that there were no audits or follow-up measures in place to ensure compliance with narcotic reconciliation procedures, and no education was provided to agency nurses. The LPN involved refused to participate in an interview regarding the incident.
Failure to Report Resident Elopement as Potential Neglect
Penalty
Summary
The facility failed to report a potential incident of neglect involving one resident who eloped from the facility without staff knowledge. The incident occurred when the resident, who was new to the facility and had a history of elopement from a hospital, climbed over the patio enclosure fence during an activity. The facility notified the resident's family and the police after discovering the resident was missing. The resident was later found unharmed and was with his son. However, the facility did not submit an incident report to the State Agency (SA) as required by their policy and federal and state law. A review of the resident's electronic health record showed the individual had multiple diagnoses, including hemiplegia and a history of stroke, and had not completed the 5-day Minimum Data Set due to the early departure from the facility. The facility's investigation report confirmed that while the family and police were notified, the SA was not informed of the incident. The Nursing Home Administrator acknowledged the failure to report the incident to the SA, stating it was overlooked after the resident was found safe.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Document Resident Transfer Following Psychiatric Emergency
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper transfer documentation for a resident with multiple psychiatric and cognitive diagnoses, including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance. The resident, who had moderate cognitive impairment and used a wheelchair, became increasingly agitated and aggressive, culminating in a physical altercation with staff and an attempt to leave the unit by force. The situation escalated to the point where the resident was administered Haloperidol and transferred to a local hospital on a psychiatric petition. Despite the severity of the incident and the transfer to the hospital, the facility did not complete or include the required transfer documentation in the resident's medical record. The only documentation available was an incident report, which was marked as privileged and confidential and not part of the medical record, and a progress note regarding the administration of Haloperidol. There were no progress notes or late entries detailing the resident's transfer disposition or destination, and the DON confirmed that a hospital transfer notice had not been completed. The facility's own "Transfer and Discharge Guideline" requires documentation of the resident's health status, the basis for transfer, and the services to be provided by the receiving provider. However, these requirements were not met in this case, as the necessary information regarding the resident's health status, safety, transfer arrangement, and destination was missing from the medical record. The deficiency was confirmed during interviews and record review, with facility leadership unable to provide additional documentation.
Failure to Document Psychiatric Incident and Hospital Transfer in EHR
Penalty
Summary
The facility failed to include critical documentation in the electronic health record (EHR) for a resident who experienced a significant behavioral incident that resulted in a psychiatric petition and transfer to a hospital. The resident, who had diagnoses including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance, became increasingly agitated and aggressive, culminating in physical altercations with staff and other residents. Despite staff interventions, including administration of PRN medications and attempts at redirection, the resident's behavior escalated to the point of property damage and threats of violence. An incident report was created by the DON detailing the resident's actions, staff responses, and the subsequent decision to transfer the resident to a hospital under a psychiatric petition. This report included information about the administration of Haloperidol and the use of emergency services. However, this incident report was marked as "Privileged and Confidential - Not part of the Medical Record," and the corresponding clinical documentation was not entered into the resident's EHR. Upon review, the DON acknowledged that the incident and the rationale for the psychiatric petition should have been documented in the resident's clinical record, as it reflected significant changes in the resident's condition and the facility's inability to provide appropriate care at that time. The facility's own policy required documentation of all services, changes in condition, and incidents in the medical record, but this was not followed in this case. No additional documentation was provided by facility leadership when requested.
Failure to Implement Physician Orders Following Resident Fall
Penalty
Summary
The facility failed to implement physician orders for a resident with multiple diagnoses, including Parkinson's disease and Alzheimer's disease, who experienced a fall resulting in a visible injury to the face. After the fall, the resident was assessed, denied pain, and was sent to the hospital for further evaluation, including a CT scan, blood work, and a urinalysis as ordered by the nurse practitioner. Upon return from the hospital, new orders included a Lidocaine 4% topical pain patch every 12 hours for 5 days. However, the order for the Lidocaine patch was not transcribed into the resident's records, and the medication was not administered. Additionally, there was no documentation or evidence that the urinalysis was completed, either at the hospital or upon return to the facility. Review of the resident's electronic health record and medication administration record confirmed the absence of the Lidocaine patch order and administration, as well as the missing urinalysis results. Staff interviews revealed a lack of clarity regarding the process for reviewing and transcribing hospital discharge orders, and the nurse practitioner confirmed not being contacted upon the resident's return. The failure to implement these physician orders resulted in the resident not receiving prescribed pain management and not having a urinalysis completed as directed.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R163, during mealtime assistance. Observations revealed that a certified nurse aide (CNA K) was feeding R163 while the resident was seated in a Broda Chair, which is a type of chair designed for comfort and flexibility. During the feeding process, CNA K was observed standing over the resident, causing portions of the pureed food to drop onto the resident's clothing. This was noted to occur because the CNA was unable to sit at eye level with the resident due to the height difference between the Broda Chair and the available dining room chairs. Interviews with CNA K and the Unit Manager (UM H) revealed that staff had not received specific training on how to assist residents seated in Broda Chairs. CNA K mentioned that the previous chair used by the resident allowed staff to sit comfortably at eye level, which was not possible with the current setup. The Director of Nursing acknowledged that staff should be seated at eye level with residents during feeding. The facility's policy on Assistance with Meals emphasized the importance of feeding residents with attention to safety, comfort, and dignity, specifically stating that staff should not stand over residents while assisting them with meals.
Breach of Resident Privacy Due to Unauthorized Package Opening
Penalty
Summary
The facility failed to maintain and respect the personal privacy of a resident, identified as R142, by opening their packages without consent. This breach of privacy was highlighted during a Resident Council meeting where R142 expressed concerns about their packages being opened by staff. R142, who has an intact cognitive status with a BIMS score of 14 out of 15, reported feeling anger and disrespect due to this invasion of privacy. The resident's medical history includes conditions such as hypertension, low back pain, and chronic embolism, and they are independent in several activities of daily living. Interviews with facility staff, including the receptionist and the facility concierge, revealed that all packages are inventoried before being delivered to residents. The facility administrator confirmed that packages are checked for contraband, either before the resident receives them or in their presence. However, the facility's policy on resident rights clearly states that staff should never open a resident's mail unless permitted by the resident. This discrepancy between policy and practice led to the identified deficiency in maintaining resident privacy.
Failure to Change Soiled Linens for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, identified as R131, by not changing soiled linens. On two consecutive days, observations revealed that R131 was lying on a bed with soiled sheets marked by a urine ring, which was wet in the center and dried around the edges. The resident, who has a diagnosis of traumatic brain injury and requires assistance with activities of daily living (ADLs), reported dissatisfaction with the living conditions, stating that the staff should change the sheets after their shower. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that linens should be changed when soiled and on shower days. A Certified Nursing Assistant (CNA) also acknowledged that residents should be checked frequently during each shift and that soiled bed linens should be changed as needed. Despite these protocols, the resident's linens were not changed, resulting in the resident sleeping on soiled and damp sheets, which contributed to their dissatisfaction with the living conditions.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to record, track, and respond to a grievance reported by a resident, identified as R15, who had intact cognition with a BIMS score of 15/15. R15, who was admitted with chronic kidney disease and type two diabetes, reported a missing item concern during a resident council meeting. R15 stated that after giving a bag of unwanted clothes to the Concierge for donation, additional clothing items were found missing from their closet. Despite informing the Concierge about the missing clothes, no grievance form was filled out, nor was the abuse coordinator notified. The facility's grievance policy requires that all grievances be promptly resolved, with the Administrator responsible for overseeing the process. However, the Concierge admitted to not following the procedure by failing to document the grievance or inform the abuse coordinator. The Nursing Home Administrator confirmed that the proper grievance process was not followed, as there were no grievance forms available for R15, indicating a lapse in the facility's grievance handling procedures.
Improper Medication Administration and Positioning
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R5, during a morning medication round. An LPN was observed administering medication to R5 while the resident was lying flat in bed, which is against the proper procedure for medication administration. This improper positioning led to the resident dropping the pills, with some falling behind the bed. The LPN retrieved three pills and disposed of them without identifying them, and then attempted to administer additional medication without confirming what had been ingested. The LPN did not contact the physician for further instructions after the incident. R5, who has a medical history including hemiplegia, diabetes, hypertension, and other conditions, was at risk due to the improper administration. The resident's care plan indicated a need for assistance with activities of daily living due to limited mobility and other impairments. The Director of Nursing confirmed that the resident should have been positioned upright to prevent choking and ensure proper medication ingestion, and acknowledged that the nurse should have contacted the physician after the medication error.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, resulting in unkempt appearances and unmet hygiene needs. Resident R107 was observed with matted hair, a long unshaven beard with food particles, and untrimmed nails. Despite being scheduled for showers and grooming, there was no documentation of these tasks being completed. Staff members acknowledged the lack of care, citing issues such as absence of personnel to braid hair and failure to document care provided. Resident R5 was found with unkempt hair and facial hair, expressing a desire for assistance with shaving. The resident's care plan indicated a need for supervision or assistance with personal hygiene, but staff only provided shaving assistance upon request. The Director of Nursing confirmed that residents should be offered shaving services, indicating a lapse in routine care provision. Resident R110 reported not receiving a shower or bed bath for two weeks, despite being scheduled for showers twice weekly. The shower log inaccurately reflected completed showers, and the Assistant Director of Nursing confirmed the resident had not been bathed since a specific date. The facility's policy required regular showers and accurate documentation, which was not adhered to, leading to unmet hygiene needs for the resident.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to adhere to standards of practice for respiratory care for a resident, resulting in improper storage of a nebulizer mask and potential cross-contamination. Observations on multiple occasions revealed that the resident's nebulizer mask was hanging on a dresser drawer next to the bed, without a storage bag. The resident, who was admitted with chronic obstructive respiratory disease (COPD) and had intact cognition, was unaware of a storage bag for the nebulizer mask. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the nebulizer mask should be stored in a bag and dated, as per facility policy. The facility's policy requires that nebulizer equipment be rinsed, disinfected, air-dried, and stored in a plastic bag with the resident's name and date.
Facility Fails to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe and functional environment for two residents, resulting in dissatisfaction and increased risk for harm. One resident reported that their bathroom did not have warm or hot water, with the hand sink only running cold water at 54 degrees Fahrenheit. The bathroom also had a loose cold-water faucet that continuously ran, cracked ceiling walls with broken plaster, peeling paint, and a loose cove base around the bathtub. Despite the Maintenance Director indicating that the unit was scheduled for remodeling, no work order had been placed to address the immediate issues with the water temperature and the leaking faucet. Another resident pointed out exposed wires protruding from the call light system on the wall, with a long white wire and an outlet cover dangling from it. The resident expressed concerns that their call light was sometimes not answered, potentially due to the hanging wires. The Unit Manager confirmed that a work order had been placed the previous week, but the issue persisted. The Maintenance Director attributed the problem to the resident pulling the wires out of the wall, while the Administrator believed the work order should have resolved the issue. The facility's preventative maintenance policy emphasizes the importance of maintaining equipment in good repair, but the issues with the call light system and bathroom remained unaddressed.
Deficiency in Annual Training for CNA
Penalty
Summary
The facility failed to ensure that annual dementia management and abuse prevention training was conducted for one Certified Nurse Assistant (CNA), identified as CNA G, out of five CNAs reviewed for in-service training. CNA G was hired on June 2, 2009, and a review of the facility-provided transcript from June 2, 2023, through June 2, 2024, revealed a lack of documentation for the required training. The Assistant Director of Nursing (ADON) confirmed the absence of records for the necessary training, which was due on June 2, 2024. The Director of Nursing (DON) also acknowledged that CNAs are expected to complete yearly training, including abuse and dementia management. The facility's policy mandates that training topics for all staff must include dementia management and resident abuse prevention, with a minimum of 12 hours per year.
Deficiency in Urinary Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments and implementation of indwelling urinary catheter care for two residents, resulting in the potential for the development of urinary tract infections and complications. Resident R901 was observed with a urinary catheter drainage bag, and despite being admitted with an indwelling urinary catheter, the orders for catheter care were not implemented until nine days after admission. This delay in care could have contributed to the resident's existing diagnoses, which included Parkinson's Disease, urinary tract infection, and other serious health conditions. Resident R902 also experienced a lack of timely catheter care upon admission. Although the resident was admitted with a urinary catheter placed in the emergency room, there was no documentation of catheter care orders until several weeks later. The resident reported not receiving catheter care initially and had to be hospitalized shortly after admission, where they were treated for a urinary tract infection. The facility's failure to document and implement catheter care orders upon admission for both residents highlights a significant deficiency in the management of urinary catheter care.
Facility Failed to Honor Resident's Right to Discharge AMA
Penalty
Summary
The facility failed to honor a resident's right to discharge against medical advice (AMA), resulting in psychological distress and depression for the resident. The resident, identified as R210, had requested to leave the facility for two days but was denied discharge until the Ombudsman intervened. The facility's Director of Nursing (DON) initially refused the discharge, citing an upcoming court guardianship hearing. The Ombudsman educated the DON on the resident's rights, leading to the resident's discharge on the same day. R210 was admitted to the facility with diagnoses including encephalitis, inhalant abuse, cognitive communication deficit, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. Upon admission, R210 had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite this, the resident was alert and oriented, as noted by a Psychiatric Mental Health Nurse Practitioner (NP) and a Licensed Practical Nurse (LPN). The facility's records indicated that the resident was deemed incompetent by the facility's psychiatric evaluation, but there was no documented evidence of a judicial ruling on incompetence. The facility's policy on resident rights states that residents have the right to exercise their rights without fear of interference. However, the facility's actions contradicted this policy, as they did not allow R210 to leave AMA despite the lack of a court ruling on incompetence. The facility's staff, including the DON and social workers, informed the resident that she could not leave due to being deemed incompetent, which was not legally substantiated. This led to the Ombudsman's intervention to uphold the resident's rights.
Failure to Ensure Appropriate Transfer Documentation
Penalty
Summary
The facility failed to ensure appropriate transfer documentation for a resident who was transferred to the hospital for hip surgery and did not return. The resident, who had diagnoses including congestive heart failure, opioid dependence, atrial fibrillation, and depressive disorder, was documented to have intact cognition. The Director of Nursing (DON) confirmed that there should have been a discharge progress note indicating where the resident went, how they were transported, and the resident's condition upon transfer. However, the clinical record lacked this essential information, which is necessary for continuity of care for the facility, the resident's doctor, and the responsible party. A review of the facility's Transfer and Discharge Guideline revealed that the facility must document the transfer or discharge in the resident's medical record and communicate appropriate information to the receiving health care institution or provider. The documentation should include the basis for the transfer. Despite this guideline, the resident's clinical record did not indicate where the resident was sent, their disposition upon leaving, or how they were transported. During the exit conference, the Nursing Home Administrator and DON confirmed that there was no additional documentation or information to provide.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to consistently obtain a resident's blood pressure readings prior to the administration of anti-hypertensive medications as ordered. This deficiency was identified for one resident who had diagnoses including chronic obstructive pulmonary disease, hypertension, hypertensive heart disease without heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. The resident was prescribed Nifedipine, Carvedilol, and Hydralazine, all of which required blood pressure monitoring before administration. However, the facility did not consistently document the required blood pressure readings, with significant gaps noted in the months of September and October 2023. During an interview and record review, the Director of Nursing (DON) acknowledged that the resident's blood pressure was not obtained according to the physician's orders. The DON confirmed that blood pressure should be taken and documented prior to administering antihypertensive medications to ensure the resident's blood pressure is not too low, which could lead to adverse effects. The deficiency was confirmed during an exit conference where the Nursing Home Administrator and DON did not provide any additional documentation or information to counter the findings.
Incomplete Discharge Instructions and Recapitulation of Stay
Penalty
Summary
The facility failed to adequately complete discharge instructions and recapitulation of stay in a timely manner for a resident, resulting in the potential for lack of communication to care providers assuming the resident's care. The resident, who had diagnoses including hypertensive urgency and cervical disc disorder with myelopathy, was discharged home from the facility. During an interview and review of the resident's clinical record with the Director of Nursing (DON), it was found that the Recapitulation of Stay document was incomplete, missing critical information such as diagnosis details, lab values, diagnostic tests, consultations, care plan goals, and practitioner contact information. The DON acknowledged that the recapitulation of stay was not adequately completed and emphasized its importance for continuity of care. The completion of this document was supposed to be a collaborative effort between nursing and social work. The facility's guideline for discharge summary and recapitulation of resident stay, dated 11/28/17, stated that a completed discharge plan and recapitulation of stay should be provided to facilitate continuity of care after discharge. However, this was not adhered to in this case. During the exit conference, the Nursing Home Administrator and DON confirmed that there was no additional documentation or information to provide before the end of the survey.
Failure to Conduct Weekly Skin Observations and Braden Assessments
Penalty
Summary
The facility failed to consistently conduct weekly skin observations for two residents and a Braden skin assessment for one resident, resulting in the potential for skin care needs to go undetected. Resident 606, who had multiple medical diagnoses including a cutaneous abscess and moderate protein-calorie malnutrition, did not receive any weekly skin observations from 10/29/23 until their discharge on 12/20/23. The Director of Nursing (DON) confirmed the lack of documentation for these assessments, which were expected to be conducted weekly according to facility guidelines. Resident 610, who was at high risk for developing pressure ulcers, also did not receive consistent weekly skin evaluations. Although the March 2024 Medication Administration Record indicated that weekly skin checks were completed, there were no detailed evaluations available in the electronic health record. Additionally, the quarterly Braden Scale assessment for pressure ulcer risk was overdue. The DON confirmed these deficiencies and acknowledged that the purpose of weekly skin evaluations is to ensure no new issues with skin integrity arise.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to perform proper sterile hygiene practices, hand hygiene, and glove usage during tracheostomy care for a resident (R624). During an observation, an LPN was seen providing tracheostomy care without following sterile techniques. The LPN sanitized his hands upon entering the room and donned PPE, including gloves and a face shield. However, the LPN did not maintain sterile technique when donning gloves, as the right-hand sterile glove fell on the bedside table before being worn. The LPN also failed to perform proper hand hygiene when switching gloves and did not remove gloves when they were considered dirty throughout the procedure. This was acknowledged by the LPN during an interview, where he admitted to not following proper sterile techniques and hand hygiene practices during the procedure. The DON confirmed that tracheostomy care should be a sterile procedure and that the nursing staff should maintain sterile technique. The resident involved, R624, had medical diagnoses including quadriplegia, anoxic brain damage, and a tracheostomy. The resident was admitted to the facility on 3/1/24 and was dependent on assistance for oral and personal hygiene. The facility's policies on tracheostomy care and hand hygiene were reviewed, revealing that hand hygiene should be followed, and gloves are not a substitute for hand hygiene. The failure to adhere to these policies during the tracheostomy care procedure resulted in the potential for tracheostomy infection and airway impairment for the resident.
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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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